Understanding the Role of mHealth and Other Media Interventions for Behavior Change to Enhance Child Survival and Development in Low- and Middle-Income Countries: An Evidence Review

"Health professionals, governments, and researchers have implemented a number of interventions to address the health of children in low- and middle-income countries (LMICs), often focusing on improving the coverage and quality of interventions of known efficacy. To date, there has been no systematic review of the science, technology, and innovation-based support related to the effectiveness of evidence-based interventions that could aid in the elimination of under-5 child morbidity and mortality in LMICs."

This article describes the research of the science, technology, and innovation (STI) evidence review team (ERT), whose goal was to (a) review the evidence and determine which STI behavioural interventions result in population-level behaviour change that could contribute to child survival and healthy development; and (b) make informed recommendations to LMICs, donors, and development practitioners on practice, programmes, policy, and research. It was written to address the goals of the Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change, which was held in Washington, DC, United States (US), June 3-4 2013. It was hosted by the United States Agency for International Development (USAID), in collaboration with the United Nations Children's Fund (UNICEF) and the National Institute of Mental Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Centers for Disease Control and Prevention, The Communication Initiative, and the American Psychological Association. The summary below is part of a special issue of the Journal of Health Communication that is a product of the Evidence Summit.

The STI ERT focused on four areas: mHealth, social transmedia, health literacy, and devices. Using a structured approach, the ERT prioritised "studies that enable causal attribution of the STI intervention on behavior resulting in desired health outcomes, the behavior itself, or on knowledge attitudes and practice." mHealth was defined as mobile technologies used to address the health needs of individuals, communities, and societies. Transmedia was defined as a "related group of media content with linkages across media forms and platforms, which may or may not have a narrative component, including traditional (e.g., radio, TV dramas, street theater) and new media technologies (e.g., SMS, social media....)" Twenty-six pieces of evidence were analysed to find "[i]deal evidence for recommendations to scale global health activities or interventions included the following: efficacy (does it work?), effectiveness (does is work in a variety of populations and contexts?), and sustainability data (cost-effectiveness, demand, adaptation into the health system, can supply meet demand at scale?"

Topic-specific practice recommendations include the following (research recommendations available in Table 1 of the document):

"Topic 1: mHealth and Provider Behaviors - Scale mHealth to provide guidance to health care workers administering malaria treatments to children under-5 years of age to enhance compliance with malaria treatment guidelines.

Topic 2: mHealth Use for Adherence to Medications - Integrate mobile messaging into compliance strategies for HIV+ patients initiating antiretroviral therapy in conjunction with additional implementation science studies to optimize (e.g., two-way vs. one-way messaging) and scale mobile text messages to HIV+ patients taking antiretroviral therapy.

Topic 3: mHealth Use for Demand Creation - Mobile texts to enhance attended skilled births should be integrated into antenatal care programs.

Topic 4: mHealth Use for Patient Compliance with Health Care Appointments - Mobile texting should be integrated into antenatal care programs under the guidance of implementation science to increase compliance with antenatal visit schedules. Mobile texting should be integrated into expanded program on immunization schedules for children and may be particularly helpful in mobile communities or refugee camp settings.    

Topic 5: Social/Transmedia for Healthy Cognitive Development and Reducing Stigmatization  - Provide access to and encourage children under-5 to gain exposure to localized high-quality educational media programming such as Sesame Street.

Topic 6: Social/Transmedia and Other Media for Healthy BMI [body mass index]in Young Children - Integrate educational and playful activities related to healthy nutrition and active lifestyles into pre-school classrooms and family workshops."

Policy and future research recommendations include:

1. "Government stewardship is needed to facilitate mHealth partnerships that leverage the strengths of relevant partners in order to best serve national health needs....Public-private partnerships may facilitate large-scale interventions bringing together diverse health, technology, and media stakeholders including regulators, development organizations, commercial enterprises, and beneficiaries. Mobile and internet content is unregulated in most countries, posing the risk of health content being disseminated that is inaccurate, misleading, or otherwise of poor quality. Government oversight and coordination with partners can ensure that mHealth content is vetted by appropriate expert bodies, consistent with national guidelines and standards for care, and responsive to the broader media and communication environment that can disseminate information that does not support healthy behaviors."
2. Policies should be adopted to protect the privacy and dignity of citizens affected by mHealth information services.
3. An integrated approach is needed to ensure greater contribution of mHealth, social/transmedia, and other media strategies to child survival priorities at multiple levels (e.g., individuals, community, and health systems). "In most LMICs, mHealth and social/transmedia interventions have evolved in an ad hoc fashion, driven by commercial interests, disease-specific programs, and uncoordinated donor and research projects. mHealth and social/transmedia policies can encourage network deployment where it is most needed, help ensure interoperable platforms, promote rational utilization within the health system, protect information security, and ensure scalable, sustainable approaches. Policies, including national communication policies, also can facilitate the systematic and mass dissemination of relevant health information and linkages with national health communication plans and strategies."
4. Increase mobile phone ownership and access by women. Mobile phone ownership has been shown to: enhance women's personal security, autonomy, mobility and self-efficacy; provide opportunities for income generation, business skills, and improved standards of living; and strengthen social networks.
5. Investments in mHealth and social/transmedia interventions should include a focus on the most vulnerable and marginalised populations.. "A systems approach that looks at the multiple social determinants of maternal and child health disparities ought to be developed to ensure that mHealth and social/transmedia media programs reach the most marginalized, do not contribute to increased disparities, and enable conditions for the benefit of the poorest and most vulnerable segments of society....misalignment of technology ownership and availability and understanding where the magnitude of child mortality is greatest - among the poorest, marginalized segments of a population who often do not have phones - is also worth exploring."
6. Research should include a focus on factors that affect adoption of interventions.
7. Include the study of underlying mechanisms in research. "For example, mHealth technologies improve case management for health care workers, which, in turn, can have positive effects on survival...In addition, mHealth technologies also affect attendance in clinics, which, in turn, affect other health outcomes...."
8. "Identify important contextual moderators in research....One group of moderators could include, for example, characteristics of behaviors that are being targeted for change. Some behaviors (e.g., early immunization) require only a few discrete episodes of action, whereas other behaviors (e.g., breastfeeding, handwashing, adherence to medications) require a more frequent adoption regimen; some behaviors are enacted by just a single person, whereas others require the joint support of one's family or community; and some behaviors are addictive, making them more difficult to change, whereas others are enacted with much greater volitional control. What is currently unknown is how these behavioral characteristics render the use of mHealth technologies more or less effective."
9. Future mHealth research should, as stated here, use rigorous designs, validated outcome measures, and important implementation information in peer reviewed studies.
10. Future research should emphasise enhanced understanding of mechanisms of change to satisfy the need for more theory-driven mHealth interventions that explore informational, cognitive, normative, and behavioural dimensions of maternal and child health.
11. Enhance capacity and develop methodologies to conduct mHealth and social/transmedia research.