mHealth to Promote Family Planning in Urban Uttar Pradesh Basil Safi, Nandita Kapadia- Kundu, Geetali Trivedi, and Diane Coraggio January 19, 2011

Urban Health Initiative 5-yr award funded by BMGF (2009 – 2013) primed by FHI, with JHU/CCP, CARE, Futures Group, and HFLPPT as key subs UHI is committed to supporting GoUP and GOI improve urban health and family planning. UHI Goal: To make a significant increases in the contraceptive prevalence rate. To increase contraceptive use, by improving access to quality family planning services; and thereby reduce unplanned pregnancies and abortions, and improve maternal and infant survival. To initiate and strengthen systems and strategies that support continuous improvements in urban health services and their utilization To replicate effective and tested strategies to an increasing number of cities.

FP Scenario in Uttar Pradesh UP is the most populous state in India with an urban population of 34 million UP has the second highest TFR (total fertility rate) in India after Bihar (NFHS 3). UP’s TFR is 3.8 compared to India’s 2.7 TFR among the urban poor in UP is 4.2 The use of modern FP methods is low (31% of women in lowest quintiles use modern contraceptives) Unmet family planning need is 22% (9% spacing & 13% limiting)

Mobile Revolution in India According to a Telecom Regulatory Authority of India (TRAI) press release, there were over 584 million mobile phone users as of March Of these subscribers, more than 360 million are from urban India (constituting 62% of the total subscribers). India has the third largest telecommunication network in the world and the second largest in terms of number of wireless connections. The Indian telecom industry is the fastest growing in the world and is projected that India will have a 'billion plus' mobile users by * (Union budget and economic survey, 08-09; TRAI, 2010)

Integrated Communication Strategy An integrated demand generation strategy for FP across media and audiences was developed in Sept 2010 following an extensive baseline and formative research process The goal: “Creation of expert, confident and consistent users of contraceptive methods of choice” The mHealth intervention is aligned with this strategy

mHealth: An Innovation in UHI mHealth as a tool for demand generation: Bringing in new users to adopt new behaviors, products or services. Serving as a method to expand social networks that fuel positive attitudes, dispel myths, and improve access to information. Sustaining practice of behaviors, use of products or services among current users for improved health outcomes.

Key Issues for mHealth Interventions Mobile phone ownership – often there is one phone per family, males family members usually have possession. Mobile phone capabilities – few have smartphones, while many have devices that can receive SMS (which is not used frequently). Literacy – urban slum populations, in particular, have low literacy rates. Loading films/videos on the cellphone is associated with “blue” or porn films (baccho ko na dikhane wali baat).

Steps in Developing the mHealth Intervention (Phase I) 1.Content Review and Strategic Analysis - synthesis 2.Design Exploration in Agra – possibilities (formative research in Agra: in-depth interviews were conducted with couples (12), mobile shop owners (2), peer educators (1), family welfare counsellors (2)) 3.Internal Studio Session – conceptualization 4.*Data Review and Analysis Workshop – feasibility 5.Heath Service User Application – design 6.Collaborative Expert Workshop – vetting 7.Development of mHealth application prototypes (February 2011) 8.Field validation of mHealth prototypes at one location (March 2011)

Steps in Developing the mHealth Intervention (Phase II) 1. Research Design and Research Tool Creation 2. Field Demonstration and Trials 3. Prototype Refinement 4. Development of final report

Main Findings of the Design Exploration Neither women nor men could report any positive experiences about FP in their community Women have less access to cell phones as the phone is generally with the husbands. A few households have separate phones for the wife and husband. SMS is not used frequently. Loading films/videos on the cellphone is associated with “blue” or porn films (baccho ko na dikhane wali baat). Games such as snake, cricket etc. are played on the cell phone

UHI Program Implications Positive experiences with different FP methods can be shared through the mHealth intervention. Men can be addressed directly through cell phones for the mHealth intervention. Women can be reached via the peer educator, womens’ groups, or spouses. IVRS can be used to promote activation events, to send follow up reminders, to promote mHealth applications and contests, such as games, films etc. mHealth interventions should amplify the activation effect and extend reach to a larger audience. M-health interventions should promote discussion with spouse, family and friends.

Proposed mHealth Applications 1)Use of games, ringtones, and ‘flashing’ 2)Behavioural films that can be downloaded at point of purchase of pre-paid cards (other opportunity for info exchange) 3) Behavioural films that can be shown during home visits of peer educators 4) Vouchers that can be sent to mobile phones 5) IVRS/SMS reminders for UHI events and programs 6) IVRS prompts for health services (for example fixed services etc.) 7) IVRS for “Antaksheri” karioke-type songs.

Pilot testing The mHealth applications will be piloted in a cluster of 5-6 slums in March 2011 Feasability will be assessed in terms of: 1.Usability 2.Extent of outreach 3.Comprehensibility 4.Recall and retention 5.User satisfaction 6.Actions undertaken after exposure to mHealth intervention (spousal communication, visit to health provider etc.)

City Level Scale-Up The mHealth intervention will be then introduced at a city level in Agra in May 2011 The population of Agra city is 1.2 million Agra has an estimated 393 slums One peer educator (community level worker) for 2000 population

Evaluation of mHealth Scale Up A quantitative evaluation using a quasi-experimental design with a pre-post survey and a comparison group (n=1200 baseline and 1200 end-line- including men and peer educators) Study Design April 2011 May 2012 (Baseline)(Endline) Intervention0_____________X_____________0 City - Agra(n = 600)(n= 600) Comparison 0__________________________0 City - TBD(n = 600)(n= 600)

Expected Outcomes 1.Increase in condom use 2. Increase in IUD use 3. Increase in consistent condom use 4.Increase in spousal communication 5. Increase in peer communication 6. Increase in visits to ORW (outreach worker) 7. Increase in visits to FW counsellor

Thanks BMGF FHI GoUP UHI partners CKS JHU/CCP

Basil Safi Team Leader, Asia Center for Communication Programs Geetali Trivedi Demand Generation Team Leader Center for Communication Programs Contact Info: