1. Mahbub Elahi Chowdhury, PhD Scientist Centre for Equity and Health Systems icddr,b Evaluating accessibility, acceptability and effectiveness of Aponjon mobile health messaging for improved maternal and newborn health behaviors and practices in Bangladesh Presentation at URC, Washington DC 23 September 2015

2. www.icddrb.org Background  There is a great potential of mobile messaging for behavioral change and improved health status with increasing access to mobile phone, globally.  In the literature, SMS has been found effective in increased coverage of immunization, treatment of diabetes and HIV/AIDS  Relatively fewer studies examined the effect of voice messages  There is also dearth of data on mobile phone based health messaging for change in behavior for improved maternal and newborn health care  Substantial evidences are needed to inform the ongoing programs and influence industry partners to invest in nationally scaled programs

3. www.icddrb.org Target beneficiaries Aponjon (MAMA Bangladesh) mHealth intervention Implementer : DNet (Launched in June 2012) Pregnancy care Dispelling myths and misconceptions Pregnancy and newborn danger signs Connecting women with local health services Benefits of breast feeding Benefits of family planning Newborn care Reminder for immunization Advise on maternal and child nutrition Contextualized mHealth messages in various areas

4. www.icddrb.org  Self / assisted registration  Message type: IVR push/pull or SMS  2 messages per week to expectant mothers from 6 to 42 week of pregnancy  2 messages per week to new mothers from first day until one year of the baby.  One message per week to husbands/ guardians  Charge: 2 Taka (US $0.03) / message  Differential charging based on socio- economic status  Free charge for 20% of the very poor subscribers Aponjon service delivery model

5. www.icddrb.org Perceived benefit of taking action Modifying behavior ― Demographic variables ― Cultural beliefs ― Socioeconomic status ― Family composition ― Ownership of phones Quantitative & qualitative study for ― Engagement with mHealth messaging and health activities ― Knowledge & awareness in care giving & care seeking Individual perception ― Perceived susceptibility ― Perceived severity Likelihood of action for desired behaviour to occur Qualitative study for ― accessibility ― acceptability ― affordability Barriers in taking action ― Expense ― Unavailability of services ― Inconvenience in seeking care Quantitative study to access ― Change in knowledge and practice of recommended maternal and newborn health care Evaluation framework of Aponjon (Health belief model)

6. www.icddrb.org Specific Objectives  Explore accessibility, acceptability and affordability of Aponjon services and the messages delivered  Assess community’s engagement with Aponjon messages and health related activities  To test effectiveness of the Aponjon intervention in Increased knowledge on maternal and newborn health care Improved practice for recommended maternal, newborn and health care  Explore accessibility, acceptability and affordability of Aponjon services and the messages delivered  Assess community’s engagement with Aponjon messages and health related activities  To test effectiveness of the Aponjon intervention in Increased knowledge on maternal and newborn health care Improved practice for recommended maternal, newborn and health care

7. www.icddrb.org Study areas: Matlab ICDDR,B surveillance areas BRAC Manoshi area B. Baria urban area B. Baria rural area Population covered by surveillance Population in urban slum (Bashanteck) General population – urban area General population – rural area

8. www.icddrb.org Research Methods Qualitative Immediately after intervention After 6 months of intervention After one year of intervention Quantitative After two years of intervention Evaluation design: Mixed method

9. www.icddrb.org Methodology and findings Quantitative assessment Presenter: Dr. Mahbub Elahi Chowdhury

10. www.icddrb.org Retrospective observational study with propensity score matching (PSM) Study design Aponjon mHealth intervention Bangladesh Aponjon user Aponjon non-user Select the best matched control

11. www.icddrb.org Women having babies <6 months of age Women having babies 7-12 months of age Used Aponjon at least 3 months in pregnancy Never used Aponjon in pregnancy Used Aponjon at least 3 months in early post- partum Never used Aponjon in pregnancy or post-partum Study population by exposure to Aponjon intervention

12. www.icddrb.org Number of households visited and mothers identified Study sites Total no. of households visited Number of mothers identified Having babies <6 months of age Having babies 7- 12 months of age Slum in Dhaka (Bhasanteck) 4,020128124 B.Baria Urban 15,852832788 B.Baria Rural 43,2352,3732,124 Matlab icddr,b comp. area 3,27111270 All 66,3783,4453,106

13. www.icddrb.org Ownership of mobile phone among mothers in study areas Mothers having babies <6 months of age (n=3445) Mothers having babies 7-12 months of age (n=3106)

14. www.icddrb.org Use of Aponjon by study population Mothers having babied <6 months of age with access to mobile phone (n=3368) Mothers having babies 7-12 months of age with access to mobile phone (n=3040)

15. www.icddrb.org Selection of subjects for interview by study population Used Aponjon >=3 months 255 Never used Aponjon 2970 Used Aponjon >=3 months 345 Never used Aponjon 2528  Selected Aponjon non-users 389 After matching Selected Aponjon users 255 Selected Aponjon non-users 484 After matching Selected Aponjon users 345 Mothers having babied <6 months of age with access to mobile phone Mothers having babies 7-12 months of age with access to mobile phone Variables used for propensity score matching: Women’s age; women’s education; husbands’ education, household asset quintile

16. www.icddrb.org Findings from the main interviews

17. www.icddrb.org Percentage distribution of respondents by mode of receiving Aponjon messages by groups Mode of receiving messages Mothers with babies 0-6 months of age Mothers with babies 7-12 months of age n=255n=345 IVR push99.298.5 IVR pull0.0 SMS0.81.5 Total100.0

18. www.icddrb.org Patterns of receiving and reading/listening to Aponjon health messages Receiving messages n=575 Reading/listening messages

19. www.icddrb.org Practice for maternal health care (19 messages) Practice for newborn health care (12 messages) Knowledge on maternal health care (22 messages) Knowledge on newborn health care (23 messages) For assessing effectiveness of Aponjon mHealth intervention we analyzed data in four different domains

20. www.icddrb.org In each domain the analysis and presentation of results followed 4 steps as shown below Assessed the association of use of Aponjon with individual outcome measures for different health messages Estimated Odds Ratios (ORs) of the composite scores adjusted for other explanatory variables Created a composite score using all the related outcome measures Examined the crude relationship of the composite score with use of Aponjon

21. www.icddrb.org Knowledge on maternal health care (22 messages assessed)

22. www.icddrb.org Statistical significance Without considering pattern of receiving and listening messages With considering pattern of receiving and listening messages* Significant79 Borderline significant42 Not significant 11 Association of use of Aponjon with increased knowledge of mothers on maternal health care: Results of the 22 messages assessed *Women who received at least 3 messages/month and carefully listened most of the messages

23. www.icddrb.org Association of the use of Aponjon for increased knowledge on different types of maternal care during pregnancy and post partum Knowledge variablesP-value Minimum required number of ANC visits0.10 Time of 4 ANC visits 0.02 Place of receiving ANC from skilled providers <0.01 Symptoms of eclampsia 0.03 Pregnancy danger signs 0.02 Place of seeking care for complications 0.51 Importance of blood grouping 0.13 Type of vaccines needed during pregnancy 0.15 Reasons for taking TT vaccination 0.04 Time of taking TT vaccination during pregnancy 0.11

24. www.icddrb.org Association of the use of Aponjon for increases knowledge on different types of maternal care during pregnancy and post partum Knowledge variablesP-value Knowledge on birth preparedness components0.16 Place of skilled delivery0.19 Indications of labor pain0.54 Need for post-partum care0.03 Recommended number of PNC<0.01 Time of 4 PNC visits0.53 Place of PNC visit0.02 Knowledge about birth spacing0.06

25. www.icddrb.org Association of the use of Aponjon for increases knowledge on different types of maternal care during pregnancy and post partum Knowledge variablesP-value Need of additional food intake during pregnancy0.38 Min. required hrs. of rest to be taken during day time in pregnancy 0.27 Recommended lying position in pregnancy0.02 Reasons for lying on the left side0.12

26. www.icddrb.org Low knowledge High knowledge Distribution of composite score on knowledge level of mothers for maternal health care % Aponjon users % Non-users

27. www.icddrb.org Percentage of respondents had high knowledge score for maternal health care by use of Aponjon

28. www.icddrb.org Percentage of respondents had high knowledge score for maternal health care by duration of use of Aponjon p<0.05

29. www.icddrb.org Percentage of respondents had high knowledge score for maternal health care by pattern of receiving and listening to messages p<0.05

30. www.icddrb.org Odds Ratios (ORs) of increased knowledge of maternal health care for use of Aponjon after controlling for duration of use and receiving & listening to messages Used 3-5 months Used 6-9 months Received <3 msgs. or not listened most of them Received>=3 msgs. and listened most of them Adj. OR95% CI  1.020.62 - 1.67  2.191.14 - 4.21  2.741.38 - 5.44  2.921.07 - 7.94 Reference group: Non-users of Aponjon

31. www.icddrb.org Practice for maternal health care (19 messages assessed)

32. www.icddrb.org Statistical significance Without considering pattern of receiving and listening messages With considering pattern of receiving and listening messages* Significant88 Borderline significant12 Not significant 109 Association of use of Aponjon with improved maternal health care practices: Results of 19 messages assessed *Women who received at least 3 messages/month and carefully listened most of the messages

33. www.icddrb.org Association of the use of Aponjon with practice of different types of maternal health care during pregnancy and post partum Practice variables P-value Received at least one ANC from skilled provider0.02 Number of ANC received <0.01 Received ANCs at recommended duration of pregnancy <0.01 Having different diagnostic tests during pregnancy 0.02 Received care from facilities for pregnancy complications (n=269) 0.07 Had blood grouping during pregnancy0.58 Had recommended number of TT shots0.19

34. www.icddrb.org Association of the use of Aponjon with practice of different types of maternal health care during pregnancy and post partum Practice variablesP-value Had adequate intake of water during pregnancy0.18 Had nutritious food intake during pregnancy0.55 Had iron-folic acid during pregnancy0.12 Had at least 2 hrs. of rest in day-time 0.04 Had less daily activities during pregnancy than as usual <0.01 Took initiatives for different components of birth preparedness 0.12

35. www.icddrb.org Association of the use of Aponjon with practice of different types of maternal health care during pregnancy and post partum Practice variablesP-value Had skilled delivery care 0.42 Number of PNC received 0.07 Received PNCs at recommended post-partum period 0.37 Had at least one PNC from skilled provider 0.21 Had Vit-A capsules after delivery <0.01 Had Vit-A capsules within 1-7 days of delivery 0.04

36. www.icddrb.org Percentage of respondents had high score for practice of maternal health care by use of Aponjon p<0.05

37. www.icddrb.org Percentage of respondents had high score for practice of maternal health care by duration of use of Aponjon p<0.05

38. www.icddrb.org Percentage of respondents had high score for prectice of maternal health care by pattern of receiving and listening to messages p<0.05

39. www.icddrb.org Used 3-5 months Used 6-9 months Received <3 msgs. or not listened most of them Received>=3 msgs. and listened most of them Adj. OR95% CI  1.030.63 - 1.70  2.681.27 – 45.66  3.611.68 – 7.74  2.410.83 - 6.99 Odds Ratios (ORs) of improved practice of maternal health care for use of Aponjon after controlling for duration of use and receiving & listening to messages Reference group: Non-users of Aponjon

40. www.icddrb.org Knowledge on newborn health care (23 messages assessed)

41. www.icddrb.org Statistical significance Without considering pattern of receiving and listening messages With considering pattern of receiving and listening messages* Significant710 Borderline significant22 Not significant 1411 Association of use of Aponjon with increased knowledge of mothers on newborn health care: Results of 23 messages assessed *Women who received at least 3 messages/month and carefully listened most of the messages

42. www.icddrb.org Association of the use of Aponjon with increased knowledge of mothers for different types of newborn health care Knowledge variablesP-value Knowledge on umbilical cord care of newborn<0.01 Days required for detachment of umbilical cord0.04 Symptoms of infected umbilical cord<0.01 Days for delayed bathing of the newborn0.03 First food for the newborn0.35 Benefits of feeding colostrums<0.01

43. www.icddrb.org Association of the use of Aponjon with increased knowledge of mothers for different types of newborn health care Knowledge variablesP-value Duration for exclusive breast feeding0.26 Benefits of exclusive breast feeding<0.01 Ways for understanding having sufficient breast milk by the baby0.06 Time of initiation of breast feeding after delivery0.98 Age of the baby for starting of weaning0.44 Types of diseases preventable by immunization<0.01

44. www.icddrb.org Association of the use of Aponjon with increased knowledge of mothers for different types of newborn health care Knowledge variablesP-value Knowledge on age of the baby for polio vaccine0.88 Place of vaccination (Score: 0-2)0.03 Age of the newborns for having jaundice0.09 Knowledge of mothers about color of babies’ stool for seeking care 0.04 Type of care to be given for diarrhea0.24 Time of seeking care for diarrhea of the baby<0.01

45. www.icddrb.org Association of the use of Aponjon with increased knowledge of mothers for different types of newborn health care Knowledge variablesP-value Knowledge on signs of a healthy baby0.85 Types of health complications of babies0.95 Place of seeking care for newborn health complication0.98 Age of the baby able to sit by itself0.33 Age of the baby able to steadily uphold the head0.22

46. www.icddrb.org Percentage of respondents had high knowledge score for newborn health care by use of Aponjon p<0.05

47. www.icddrb.org Percentage of respondents had high knowledge score for newborn health care by duration of use of Aponjon p<0.05

48. www.icddrb.org Percentage of respondents had high knowledge score for maternal health care by pattern of receiving and listening to messages p<0.05

49. www.icddrb.org Used 3-5 months Used 6-9 months Received <3 msgs. or not listened most of them Received>=3 msgs. and listened most of them Adj. OR95% CI  0.910.45 - 1.83  3.431.16 - 10.13  1.460.99 - 2.14  1.761.08 - 2.87 Odds Ratios (ORs) of increased knowledge of newborn health care for use of Aponjon after controlling for duration of use and receiving & listening to messages Reference group: Non-users of Aponjon

50. www.icddrb.org Practice for newborn health care (12 messages assessed)

51. www.icddrb.org Statistical significance Without considering pattern of receiving and listening messages With considering pattern of receiving and listening messages* Significant01 Borderline significant02 Not significant 129 Association of use of Aponjon with improved newborn health care practices (12 messages assessed) *Women who received at least 3 messages/month and carefully listened most of the messages

52. www.icddrb.org Association of the use of Aponjon with improved practice of different types of newborn care Practice variablesP-value Had recommended practice of umbilical cord care of the newborn 0.02 Had delayed bathing of the newborn 0.73 Fed colostrums as the first food to the newborn 0.43 Breastfed baby within 1hr of delivery 0.49 Exclusively breastfed babies up to 6 months 0.49

53. www.icddrb.org Association of the use of Aponjon with improved practice of different types of newborn care Practice variablesP-value Started weaning at 6-7 months of the age of the babies 0.06 Number of different types of food stuff given for weaning 0.41 Started vaccination of babies from 40-45 days of babies’ age 0.62 Number of vaccines of different types given to the newborn 0.17 Seeking care from skilled providers for newborn health complication (n=449) 0.05 Talked to baby since birth 0.21 Played with babies with colorful toys 0.36

54. www.icddrb.org Percentage of respondents had high score for practice of newborn health care by use of Aponjon p>0.05

55. www.icddrb.org Percentage of respondents had high score for practice of newborn health care by duration of use of Aponjon p>0.05

56. www.icddrb.org Percentage of respondents had high score for practice of newborn health care by pattern of receiving and listening to messages p<0.05

57. www.icddrb.org Used 3-5 months Used 6-9 months Received <3 msgs. or not listened most of them Received>=3 msgs. and listened most of them Adj. OR95% CI  0.690.38 - 1.24  1.590.39 – 6.45  1.040.72 – 1.51  1.681.08 – 2.63 Reference group: Non-users of Aponjon Odds Ratios (ORs) of improved practice of newborn health care for use of Aponjon after controlling for duration of use and receiving & listening to messages

58. www.icddrb.org Summary findings In Bangladesh accessibility to mobile phone among the new mothers in the community is quite high Own mobile phone 61% Accessibility to others’ phone 37% However, only about 8% and 12% of the respondents used Aponjon at least for 3 months during pregnancy and early post-partum respectively About 16% of the Aponjon subscribers received <=2 messages (out of 8) per month Only about one-third (35%)of the respondents carefully listened to most of the messages

59. www.icddrb.org Summary findings Respondents who subscribed Aponjon at least for 3-5 months and received at min. 3 messages per month & carefully listening to most of the messages had effect on –  Increased knowledge on maternal health care  Improved practice of maternal health care  Increased knowledge on newborn health care

60. www.icddrb.org Summary findings Minimum 6 months’ of use of Aponjon also had effect on –  Increased knowledge on maternal health care  Improved practice of maternal health care  Increased knowledge on newborn health care

61. www.icddrb.org Summary findings Minimum 6 months’ of use of Aponjon along with receiving at least 3 messages per month & carefully listening to most of the messages had effect on –  Increased knowledge on maternal health care  Improved practice of maternal health care  Increased knowledge on newborn health care  Improved practice of newborn health care

62. www.icddrb.org Conclusions Just subscribing the Aponjon did not mean that women received and carefully listened all the messages Using Aponjon for 6 months had effect in increased knowledge and practice of maternal health care. However, for an effect with a shorter exposure (i.e. 3-5 months), women needed to receive min. 3 messages per month & listen all of those carefully The above mechanism also functions for increased knowledge on newborn health care However, for an effect on practice of newborn health care, women needed to use Aponjon at least for 6 months and receive min. 3 messages per month & carefully listen to most of the messages

63. www.icddrb.org Recommendations To have the effect of the Aponjon intervention in the population level, additional efforts should be given for increased subscription rates along with emphasis for continuation of services for longer duration The reason for not receiving and carefully listening to all the messages should be further explored and accordingly programmatic initiatives should be taken to overcome these problems for greater benefit of the intervention

64. www.icddrb.org  Dr. Lumbini Roy, Ex-Communication Specialist, icddr,b developed questionnaires and participated in training of the interviewers  Mr. Zahed Shafiqur Razzak, Sr. Field Research Officer, icddr,b, developed questionnaires, coordinated the field implementation  Ms. Tasnuva Wahed, Assistant Scientist, icddr,b, coordinated the field implementation  Mr. Maksudur Rahman, and Shajratul Alam Statistical Officers, icddr,b performed the statistical analysis Study team members Special thanks to the D.Net team members for their all out co-operation at every stages of this study since development of the project proposal

65. www.icddrb.org Acknowledgements This study has been fully funded by the USAID TRAction Project to icddr,b This study is made possible by the support of the American People through the United States Agency for International Development (USAID). The findings of this study are the sole responsibility of icddr,b and do not necessarily reflect the views of USAID or the United States Government. Translating Research into Action, TRAction, is funded by United States Agency for International Development (USAID) under cooperative agreement number GHS-A-00-09-00015-00. The project team includes prime recipient, University Research Co., LLC (URC), Harvard University School of Public Health (HSPH), and sub-recipient research organizations.