Assessing the Impact of Mobile Phone Technology to Improve Health Nutrition and Population (HNP) Service Utilization in Rural Bangladesh Through Pilot Intervention
Assessing the Impact of Mobile Phone Technology to Improve Health Nutrition and Population (HNP) Service Utilization in Rural Bangladesh Through Pilot Intervention
1. Burden:

 In global perspective, it is estimated that the lives of 150,000 women could be saved
 each year worldwide with access to sufficient family planning services. It is indicated
 that only 26 percent women received four or more antenatal care (ANC) visits during
 their pregnancies, while 67.7 percent received at least one ANC during their pregnancies
 which are the great challenges for ensuring safe motherhood in the country. As a part of
 safe motherhood, it is estimated that only 28.8 percent deliveries are being conducted
 in health facilities in the country. In case of postnatal care (PNC), from 2008 to 2010,
 only 27 percent of women received PNC for their last deliveries from a medically-trained
 provider within two days of their delivery. Despite the tremendous success of expanded
 programme on immunization (EPI) in Bangladesh, a substantial number of children are not
 fully vaccinated under EPI as data shows 82 percent were fully vaccinated by the age of
 12 months.

 2. Knowledge gap:

 Use of technology for covering all or major components of primary health care (PHC) is
 yet to be developed and tested in Bangladesh. Further, no such initiative has yet been
 taken focusing community clinic (CC) to ensure equity of services in Bangladesh.

 3. Relevance:

 At present in Bangladesh, the CCs cater the services on family planning, maternal neonatal
 and child health (MNCH), health education for the rural people by using e-health strategy as
 the community health care provider (CHCP), newly recruited staff of community clinic are
 equipped with internet connected laptop service. So, updated technology for updating
 information, follow up and referral in primary health care can be used to increase the
 utilization of health services.

 Hypothesis (if any):

 Use of smart phones by community level healthcare providers will increase utilization of
 reproductive health (RH) and family planning (FP), MNCH, integrated management of childhood
 illness (IMCI), EPI and other PHC services at rural communities in Bangladesh.

 Objectives:

 To develop and test a mechanism as well as assess the impact of mHealth strategy to improve
 RH and FP, MNCH, IMCI, EPI and other PHC services in rural communities of Bangladesh.

 Methods:

 The service delivery personnel who are providing the services to the community people at
 different levels (community clinic, union health and family welfare centre, upazila health
 complex) will be equipped with smart phones having the facilities for text messages, voice
 messages as well as internet and data capturing. Training on handling of the smart phones,
 data capturing and monitoring will be provided to service providers in each upazila. They
 will be trained to input, edit, verify and monitor the data on different services through the
 software installed in their smart phones. The community clinic management and support groups
 will be oriented and motivated on mobile phone based registration, notification and referral
 to the health facilities.

 Outcome measures/variables:

 This will be a quasi-experimental pre-post design study and evaluation will be done through
 comparing antenatal care (ANC), postnatal care (PNC), and contraceptive prevalence rate (CPR)
 and EPI coverage before and after its implementation in the study versus comparison areas.
 The study will be conducted over a period of 30 months.
Introduction In Bangladesh, about 2 million new faces are added to the population annually
 with a growth rate of 1.4% . Last Health Population and Nutrition Sector Development
 Programme (HPNSDP) of the Ministry of Health and Family Welfare (MOHFW) had set a target of
 total fertility rate (TFR) of 2.0 and contraceptive prevalence rate (CPR) of 72 by 2016 which
 is currently 2.3 and 61.2 respectively. It is necessary to increase the age at first birth as
 data indicates almost half of women giving birth by age 18 and nearly 70% giving birth by age
 20. It is indicated that only 26% women received four or more antenatal care (ANC) visits
 during their pregnancies, while 68% received at least one ANC during their pregnancies which
 are the great challenges for ensuring safe motherhood in the country. As a part of safe
 motherhood, it is estimated that only 29% deliveries are being conducted in health facilities
 in the country. In case of postnatal care (PNC), from 2008 to 2010, only 27 percent of women
 received PNC for their last birth from a medically-trained provider within two days of their
 delivery . Despite the tremendous success of EPI in Bangladesh, a substantial number of
 children are not fully vaccinated under EPI as data shows 82% were fully vaccinated by the
 age of 12 months. In case of diarrhoea among under 5 years of age, 25% received treatment
 from a health facility or healthcare providers. Thirty-five percent of the children under 5
 years who had acute respiratory infection (ARI) received treatment from a health facility or
 healthcare providers. More than six of every ten children with fever sought treatment from
 the private medical sector. Although 90% of children are breastfeed until age 2, as
 recommended, but 36 percent of children less than age 6 months are out of exclusively
 breastfed. Though the health indictors in Bangladesh are improving, these rates are behind
 from the target.

 In recent years, mobile phone use in healthcare (mHealth) has emerged to augmented of
 healthcare services where the population is underserved especially in rural areas . In a
 systematic review, Tamrat and colleagues (2011) highlighted the scope of mHealth along the
 stages of the 'continuum of care' for maternal, newborn and child healthcare [8]. mHealth
 programs are being used for pregnancy tracking, appointment reminders for antenatal care, and
 SMS-based health education during pregnancy. During the birth, mHealth can be used for
 point-of-care remote consultation, facilitate referral to health facility; facilitate access
 to health facility and to promote timely contact with community health workers. For
 postpartum and newborn care, mHealth can be used for maternal and infant growth monitoring,
 timely reminders for immunization .

 In Bangladesh, mHealth and eHealth initiatives are being implemented by MOHFW and different
 organizations and donors are supporting to the initiatives. This initiative will complement
 with existing health systems and contribute to increase effectiveness of HPN services by
 using mobile phone based technologies.

 The Government of Bangladesh has placed a high priority on eHealth, which is reflected in the
 ICT Policy 2009. The strategic areas/issues relevant to health in the ICT Policy 2009 include
 the following (Clauses 7.1-7.4 of ICT Policy): 'Improve healthcare delivery management
 through use of telemedicine and modern technology; create awareness at all levels, including
 hard-to-reach areas with particular importance in making maternal, child and reproductive
 care available; ensure quality of care and increase the capacity of health care delivery
 system'. But use of technology for covering all or major components of primary health care
 (PHC) is yet to be developed and tested in Bangladesh. Further, no such initiative has yet
 been taken focusing community clinic (CC) to ensure universal health coverage in Bangladesh.

 At present, in Bangladesh, the CCs can cater the services on family planning (FP), maternal
 neonatal and child health (MNCH) and health education for the rural people by using eHealth
 strategy as the community health care provider (CHCP) and other staff of CCs are equipped
 with internet connected laptop service . One recent study findings show that 33% rural
 married women and 69% of their family members have mobile phones. Therefore, the MOHFW,
 icddr,b and Ethics Advance Technology Limited (EATL) have taken this initiative to utilize
 mobile phone technology to improve HPN service in rural areas of Bangladesh. This study will
 be implemented with the aim to develop and test a mechanism of mHealth strategies as well as
 assessing the impact in improving reproductive health and family planning, maternal neonatal
 and child health, integrated management of childhood illness, expanded programme on
 immunization, and other primary health care services in community level in rural areas of
 Bangladesh. This is an evidence based research for HPN services using mobile technology and
 proposed extension of the project and integrated with health system of the Government in
 Bangladesh.

 This study aims to: 1) Improve coverage of ANC, delivery care and PNC; 2) Improve use of
 family planning services among newly married couples to increase the age at first birth; 3)
 Improve utilization of MNCH services including EPI services to reduce neonatal mortality
 rate; 4) Assess acceptability of providing health education regarding family planning,
 nutrition, breastfeeding; 5) Establish technology based referral linkage of CCs with the
 higher facilities.

 Methods Study design

 The study will follow a quasi-experimental pre-post design. Evaluation will be carried-out
 through comparing ANC, delivery care, PNC, contraceptive prevalence rate (CPR) and EPI
 coverage before and after its implementation between the study and the comparison areas.

 Study area

 The study will be conducted in two selected administrative divisions of Bangladesh: one high
 performing (Rajshahi) division and one low performing (Chittagong) division. Based on the
 performance of health and family planning indicators, the selected districts are: Natore from
 the high performing (Rajshahi) division and Cox's Bazar from the low performing (Chittagong)
 division. In high performing division, one upazila (Bagatipara) of Natore district will be
 the intervention upazila while Baraigram of the same district will be the comparison upazila.
 On the other hand, one upazila (Chakaria) of Cox's Bazar district will be the intervention
 upazila while Ramu will be the comparison upazila. A total of 4 upazilas (2 intervention and
 2 comparision upazilas) from the two divisions will be selected for the study.

 Timeline The study will be conducted over a period of 30 months in three phases: (i)
 inception phase (6 months for IRB approval, recruitment of staff, stakeholders' meetings at
 different levels, mobile apps and survey instrument development, training of GoB staff on
 interventions, baseline survey and inception report preparation); (ii) intervention
 implementation phase (18 months for implementation of intervention; (iii) evaluation phase (4
 months for end line data collection, data analysis and report writing, sharing of the results
 and evidence for future scaling up through dissemination, finalization of report and
 publications).

 Mobile apps development and testing

 The mobile apps were developed by a team a team from Ethics Advanced Technology Limited
 (EATL). After developing the apps study team did the filed test and piloting in other than
 project areas. After receiving the feedback, study team tried to make the easiest apps. The
 SMS messages were developed by a team comprising of general physicians, immunization expert,
 family planning expert, health systems expert, health care provider, GoB officials and non
 government officials. After developing the SMS messages in Bengali, study team sent these
 messages to several individuals in the pre-test stage including persons who can only read SMS
 and have no formal education qualifications. After receiving the feedback, study team tried
 to make the contents of the SMS suitable for the general population. Investigators will
 ensure that all our participants in the study can read the SMS messages by themselves or
 someone in the family who can describe the messages to them if they do not understand.

 Interventions

 The Bangladesh government provides primary health care services to all citizens through a
 three-tiered healthcare service delivery system: the community clinics, each for 8000 people;
 the union health and family welfare centres (UH&FWCs), each for 25,000 people; and the
 upazila (sub-district) health complexes (UHCs) with an out-patient and an emergency
 departments, 50 in-patient beds and an operating room, each for 250,000 people, which
 coordinate services between different tiers. The service delivery personnel at different
 levels (CC, UH&FWC, UHC) will be equipped with Smartphones having the facilities for text
 messages, voice messages as well as internet and data capturing. Smartphones will be provided
 to them from the project. Training on handling of the Smartphones, data capturing and
 monitoring will be provided to upazila Health and family planning officer (UHFPO), upazila
 family planning officer (UFPO), medical officers (health and family planning departments),
 the statistical assistant, family welfare visitors (FWVs), sub-assistant community medical
 officers (SACMOs), nurses and medical technologist, health inspectors (HIs), family planning
 inspectors (FPIs), assistant health inspectors (AHIs), health assistants (HAs), family
 welfare assistances (FWAs), community health care providers (CHCPs) and other related service
 providers in each upazila. They will be trained to input, edit, verify and monitor the data
 on different services through the software installed in their Smartphones. The community
 clinic management and support groups will be oriented and motivated on mobile phone based
 registration, notification and referral to the health facilities. A team from Ethics Advanced
 Technology Limited (EATL), a software development company will provide technical support to
 develop the device, train concerned personnel, and continue support in smooth functioning of
 the system. The interventions to be tested are as below:

 1. Identification and registration of pregnant women and services for them

 For fixing the target population for ANC, PNC and delivery care, pregnancy
 identification and registration is the initial activity. A routinely updated list of all
 the pregnant women of every village is supposed to be available with all FWAs. However,
 this list can be updated from information of other service providers like HAs, FWVs, and
 CHCPs. Pregnant women will be identified and registered in the following ways: from
 routine community visits of health and family planning workers; from EPI centres when
 the pregnant mothers visit for receiving TT vaccine; from registers of pregnant mothers
 with community clinics; from satellite sessions conducted by FWVs; from registers of
 pregnant mothers maintained by FWVs at UH&FWCs and UHC; from combined meetings held at
 community clinics, UH&FWC and UHC, and; from registers of pregnant mothers maintained by
 NGOs who are working on reproductive, maternal and child health.

 Registration process of pregnant women: The Smartphones carried by the healthcare
 service providers will contain a customize software for registration of pregnant women
 with information (name of pregnant women, age, address, last menstruation period (LMP)
 and mobile phone number) and updating and sending to the server. A unique identification
 (ID) number will be automatically created followed by data upload to the server and will
 be given to the pregnant women. This unique ID will ensure her to get necessary
 healthcare services within the study area.

 Service delivery system for ANC, delivery care, essential newborn care and PNC: Pregnant
 women will receive auto reminder through their mobile for ANC visit prior to their
 scheduled date for each visit via voice message followed by text message. The schedule
 visit date will be calculated by the system automatically from the LMP. The reminder
 will include the date, time, available facilities and services for ANC, and will be sent
 to the women several times to ensure their ANC visits. The system will also send auto
 reminder through text message to the concerned service provider to check whether the
 pregnant woman has received ANC or not. The service provider will provide and update the
 ANC services and status of the particular pregnant woman. Apart from ANC reminders, the
 pregnant women will also receive voice message on healthcare during pregnancy, danger
 signs and birth preparedness.From the LMP, the expected date of delivery (EDD) will be
 calculated by the system and reminder will be sent to the pregnant women automatically.
 The pregnant woman will receive auto voice messages/text messages containing necessary
 information related to institutional delivery according to her EDD.

 2. Birth notification

 The pregnant women will be encouraged and trained to notify immediately after the
 delivery through SMS by themselves or by anyone on behalf of the delivered women. After
 receiving birth notification, system will automatically update the particulars of
 newborns including date of birth, PNC schedule, EPI vaccination due dates for the
 newborn and location of service centre. The system will also send auto reminder to the
 mothers with a specific time schedule for PNC visit, newborn care visit and schedule of
 receiving vaccines for the newborn.

 3. Childhood vaccination services under EPI

 After the outcome of the delivery of the registered pregnant women, the system will
 receive the birth notification as mentioned in the birth notification process.
 Mothers/caregivers of the newborn will receive auto voice/text messages one day prior to
 their visit to the vaccination centres. A second reminder will be sent to the parents of
 all the targeted children through their own phones or their family's numbers collected
 earlier on the vaccination day at the beginning of the vaccination session for bringing
 their children for vaccination. A third reminder will be sent to the mothers/caregivers
 of the children who were not vaccinated after receiving the second reminder as scheduled
 on that day. The system will also provide auto reminder to the concerned service
 provider including EPI session wise list of targeted children. The service providers
 will update the status of vaccination of session using their Smartphone and the system
 will allow the service providers to see the drop-out and left out cases.

 4. Newly married couple identification

 Newly married couple identification and registration is the initial activity for fixing
 the target population for FP service. A routinely updated list of all the newly married
 couple of every village is supposed to be available with all FWAs. However, this data
 can be updated from other service providers also, such as HAs, FWVs, CHCPs. Couple
 identification and registration will be done through following ways: during their
 regular community visits; from service delivery points like community clinics, UH&FWCs
 and UHC; at satellite sessions by FWVs; and from other NGOs who are working on
 reproductive health.

 Newly married couple registration process: The Smartphones will contain specific
 software for newly married couple registration where some necessary information (names
 of newly married couple, age, address, LMP, current contraceptive use, future fertility
 plan and mobile phone number) can be updated and sent to the server. A unique ID number
 will be automatically created followed by data upload to the server and will be given to
 the couple. This unique ID will ensure her to get necessary family planning services
 within the study area.

 Family planning service delivery system:Based on the information gathered through couple
 registration process, the system will automatically generate the most suitable family
 planning options for a couple and send the information to the concerned service
 providers. The service provider will motivate the client for the most suitable FP method
 option generated by the system and after taking the consent they provide the method
 accordingly. The system will send auto messages to the couples through their mobile
 phones about importance of birth spacing and use of FP methods, information related to
 services at CCs and UH&FWCs. The service provider will update information to the system
 to maintain the information of FP method use and regular follow up status which will be
 recorded in server.

 5. e-Referral

 There will be online referral system for the registered women and their children for
 ANC, PNC, delivery care, neonatal management, IMCI and other complication management in
 which healthcare providers from lower facilities can refer a patient to the higher
 facilities. The women will be identified in the higher facilities by their unique ID.
 The service providers will enter referral data to the system during the referral process
 and the patients and providers from higher facilities will get system generated
 reminders about the referral. The service providers in higher facilities will be able to
 check the health status and cause of referral using patient's unique ID number from the
 system and will manage accordingly as well as update the given management to the system.
 If the referred woman does not visit the referral facility, she will receive repeated
 reminders auto-generated by the system to comply the referral; and the service provider
 who referred the mother/client will be able to see the status of the client using smart
 phone.

 6. e-monitoring

 There will be web based monitoring system to oversee the progress and status of all the
 activities under this study for policy makers, programme peoples and other supervisors from
 national to the union levels. All these data will be available in the central database which
 will be visualized and accessible at all concerned levels through internet in particular
 website. They can constantly follow up the progression and healthcare delivery system of the
 respective area and provide regular feedback, when necessary. There will be provision of
 auto-generation of reports for each and every activity through the system by area and service
 provider specific. Figure-2 shows the interventions implementation process and Figure-3 shows
 the snap shots of apps developed.

 Study population The study populations will be: (i) currently married women of reproductive
 age not currently pregnant and did not have delivery within last 6 months; (ii). Mothers of
 children aged 12-23 months for assessing children's vaccination coverage; (iii). Mothers of
 children aged 0-11 months for assessing ANC, delivery care, PNC and vaccination coverage; and
 iv. The healthcare service providers.

 Procedures for selection of sample clusters: In the catchment area of a CC there are 8
 routine EPI centers (including the CCs one) each serving, on an average, ~1000 people (or
 ~235 households). The catchment area of the EPI centre will be treated as 'cluster'. Given
 the crude birth rate of ~20 per 1000 population per year there will be 20 mothers who have a
 infant aged 0-11 months eligible to provide information on ANC, delivery care and PNC; and
 another 20 mothers who have a toddler aged 12-23 months eligible to provide information on
 child vaccination. As such, 33 EPI centers from the list of EPI centers of an upazila (with
 at least one EPI centre per CC) in the selected sub-district will be randomly chosen for
 survey.

 Selection of households: The second stage will be selection of households with eligible
 respondents in each sampled cluster (or EPI centre catchment area). With their consent all
 mothers with child aged 0-11 months or 12-23 months will be interviewed for maternity care
 and vaccination respectively. Women (married non-pregnant or did not delivered baby in <6
 months) eligible for family planning use are many in a cluster. Therefore, a woman eligible
 for family planning method use living in the household next to the mother with a child aged
 0-11 months will be interviewed. The same sample selection procedures will be followed in the
 comparision areas.
Inclusion Criteria:

 -  Currently married women of reproductive age not currently pregnant and did not have
 delivery within last 6 months

 -  Mothers of children aged 12-23 months for assessing children's vaccination coverage,
 and

 -  Mothers of children aged 0-11 months for assessing ANC, delivery care, PNC and
 vaccination coverage

 -  The service providers