RESERVE CONFIDENCE AND IMMEDIATE HITCH: USE OF MOBILE PHONE MESSAGING TO IMPROVE MATERNAL AND CHILD HEALTH BEHAVIOR IN INDIA Avishek Hazra, M. E. Khan, Subrato Mondal, Kara Tureski February 10, 2016 International SBCC Summit, Addis Ababa, Ethiopia

Background Mobile technology provides an opportunity to use it as a tool for improving health behaviors Globally, lots of experiments happening on m-health In India, 80% population (960 million) are subscriber of mobile phone 90% families in Uttar Pradesh, a state with 200 million population, own atleast one mobile phone Ownership of mobile phone among women is low, and mostly kept by men So, is mobile phone a viable medium to reach to women with health messages?

Objectives An implementation research was conducted in Uttar Pradesh to Examine whether provision of information on maternal and child health to husband through mobile phone enhance their knowledge and trigger discussion on it in family; and Study whether such discussions result in adoption of healthy behaviors A husband listening to intervention message in Chirgaon, Jhansi; Photo credit: Balbeer Kandari

Study design and study area Quasi-experimental design was used Eligibility criteria to include a household in the study were:  index woman was pregnant for 6 or more months;  husband of index woman owned a functional mobile phone; and  husband was living with family = Experimental block = Control block Uttar Pradesh Jhansi In 2014, after four months of intervention, 881 husbands and 956 women were interviewed

Intervention 8 voice messages developed in Hindi language 5 health behaviors - antenatal checkup, postnatal checkup, early breastfeeding, clean cord care and delayed bathing Messages were sent to husband’s mobile phone twice a week for four months At different time points - 9 am, 1.30 pm and 7.30 pm Each message was of seconds Messages ended encouraging husbands to discuss the messages with their wives and family members Informed cosent was taken from each of them to send voice message during house listing at the beginning of study

The sample of the two groups matched well with respect to husband’s characteristics like age, religion, occupation and exposure to mass media The control area had higer percentage of scheduled caste or tribe husbands and those with no education or up to primary education Socio-demographic characteristics House listing at Chirgaon, Jhansi; Photo credit: Avishek Hazra Women in intervention area also matched with those from control area, except that education level was higher in intervention area

Reach of voice messages Number of husbands who agreed to participate in the study (N=640) Voice messages not sent due to DND activation (N=148; 23%) Voice messages sent (N=492; 77% ) Interviewed (N=428; 87%) Could not be interviewed (N=64; 13% ) Received voice message (N=147; 34%) Not received voice message (N=281; 66% ) Discussed messages in family (N=68) 46% among received 16% among interviewed Did not discuss messages in family (N=79) 54% among received

Reasons for not hearing all the messages were:  ‘busy at work’ (85 percent) and  ‘disconnected the call after hearing once or twice’ (20 percent) Profile of listeners and non-listener husbands were similar and no significant differences were observed A husband said, “…my job is painting equipment, most of the time my both hands remain either engaged or colored with paint and I cannot take out the mobile phone from my pocket. Later when I see the phone and find any missed call from a saved number, I call back.” (35 years, educated up to class 9, painter in a factory) Reasons of not hearing messages

39 percent of the husbands asked their wife and 13 percent asked their mother to follow the messages they heard “…I have a facility in my mobile to record any call. So, after the first message, when I realized the messages are for my to-be-born baby and my wife, I used to record the messages and replay those in front of my wife”. (26 years, graduate, Panchayat Mitra) “…when I got such calls with health information, I used to put my mobile phone on loud speaker so that my family members could listen to it.” (33 years, educated up to class 12, shopkeeper) Interviews with women revealed presence of more than one family member during discussion: “The first time when he (husband) told me about getting a check-up for Riya (respondent’s daughter), my paternal aunt, sister-in-law and elder sister were present. He also told me to breastfeed well and not to give anything else other than breast milk.” (22 years, Educated up to class 8, Housewife) Discussion of messages in family

Husband’s knowledge on maternal and child care Knowledge Heard messages Didn’t hear messages Importance of at least one ANC checkup after 6 th month of pregnancy Need for a PNC for mother and newborn within 7 days of delivery, even if they are fine A baby should be first breastfed within an hour73.0**50.9 Nothing should be applied on baby’s cord stump and keep it clean and dry 71.8**15.7 A baby should be given first bath after 2 days of delivery 87.5**72.4 Levels of knowledge among husbands who heard the messages were significantly higher for 3 of the 5 health behaviors than those who did not hear the messages or were not exposed to the intervention

If husbands discussed the messages with family, chances of wives’ practice of at least three behaviors improve significantly, after controlling for socio-demographic factors Practice of healthy behaviors Received ANC in 3 rd trimester At least one PNC within 7 days Early breast- feeding Clean cord care Delayed bathing by at least 2 days Husband discussed with wife about the behavior – NO -- YES 1.72**3.02** **

Conclusion Communication intervention using mHealth was found to be effective for behavior change Feasibility of such intervention, however, need to be tested with longer span of intervention This study also addressed a neglected but critical area -- male involvement in improving family health outcomes Results indicated that mobile phones can be used as a complementary medium along with other mass-media, mid-media and interpersonal communication channels to reach to women with health me ssages

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