1. Innovating, Adapting, Learning, Expanding and Excelling: Improving Interpersonal Communication around the globe through a mobile distance education platform
Heidi Good Boncana & Lindsey Leslie
May 2017
In 1988, in recognition of the crucial role of communication in public health, JHU established the Center for Communication Programs, better known around the world as CCP. Since that time, CCP’s programming, teaching and research has literally touched billions of people. Today, CCP has over 60 projects that reach people in more than 30 countries and has yearly expenditures of over $100 million. Our major donors include the United States Agency for International Development, the Bill & Melinda Gates Foundation, UNICEF, DFID, and more. CCP is now based within the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health. Our work focuses on four key pillars:
Research, monitoring and evaluation,
Social and behavior change communication
Capacity strengthening
Knowledge management
We support frontline community health workers, facility-based staff, health program managers, and Government/USAID/other donors/decision-makers in getting the right tools, with the right information, at the right time.

2. Interpersonal Communication (IPC)
Tailored exchange or sharing of information, thoughts, ideas and feelings between two or more people to address behavioral determinants of health. IPC can be one way or two way. It can also be verbal, non-verbal or both.
Definition is from Health Compass:
Interpersonal communication is an important mechanism for health behavior change. People often engage and communicate better when they have shared values and attitudes or can at least see things from each other’s perspective and accept each other’s values and attitudes. IPC is influenced by attitudes, values, social norms and the individuals’ immediate environment. Types of IPC include one-on-one interactions (at clinic or community), small group interactions, large group discussions, hotlines, supportive supervision visits, peer education, parent-child or inter-spousal communication.
It can be used in a number of settings, across health topics and by multiple cadres of health workers and community members. Often, IPC involved one on one or small group conversations that are tailored for the client’s need. A trusted source (for example a frontline health worker) may provide important or even sensitive information to the client. The client can then follow up with that source in the future if more information is necessary.

3. Interpersonal Communication (IPC)
Pros: Cons: Personalized for client needs Low fidelity Leverages personal connections Room for personal bias Encourages experience sharing Heavily dependent on FHW skills
However, IPC does have limitations:
It can be difficult to maintain the fidelity in how IPC is done. Training can help, but frequent trainings are necessary to ensure consistency in approach and delivery. Given that IPC can be less formal and occur in more intimate settings (i.e. households), other factors may influence the counseling session (family members, children, house work, etc). Often, if can be difficult for those providing IPC to separate their personal biases from the counseling session. Or, they may have too much on their plate and may not be able to recall all the critical information the client needs to know.

4. Pairing Individual Counseling & mHealth
Personal Counseling
A combination of both mhealth videos followed by interpersonal counselling is the ideal scenario: clients have a opportunity to get their doubts and queries addressed by a knowledgeable source
on demand
At CCP, we thought to use the benefits of mHealth and other forms of media to improve IPC interactions. By combining multiple levels of strategic and persuasive communication in a single tool, we believed it was possible to enhance the conversation resulting in a more substantial discussion between the person providing IPC (i.e. health worker) and the client.
It should be noted that the app is a supplement/ complement to the conversation, not a replacement. Traditional counseling methods rarely enable the FHW to quickly access information on multiple health topics at the touch of her fingertips, but the tool we develop does just that.
mHealth Videos

5. Why OppiaMobile? Ease of Content Management:
Integrated with Moodle most common open source Learning Management System allowing for low cost development and deployment of content
Analytics:
Usage statistics collected by the app and uploaded to the admin server whenever there is a connection. Statistics reflect what resource was used and when and for how long.
Works Offline:
No internet connection necessary to run the app once it is fully registered and media loaded
Open Source:
No licensing requirements
Code and functionality can be freely shared
Easy Access:
Available for download from Google Play
Adaptable To Many Languages:
Adaptable to almost any language for an Android based device.
To build the initial tool, we used the Oppia Mobile technology as it was a user-friendly distance education platform. In fact, the technology was originally designed for use by Frontline Health Workers (FHWs). Over the course of 4 years, we’ve tailored the app for use in 4 separate country program teams to meet the specific communication needs of different cadres of FHWs which I’ll speak about later in the presentation.
Review slide bullets
More information available:

6. Multi-Purpose Tool Counseling Tool:
Decision support tool, offering need specific counseling using AV content that is standardized, motivational and persuasive
We found that the generic Oppia Mobile app can potentially serve 3 functions: training, communication (SBCC), and managerial:
The self-learning tool is a job aid for the FHW; it strengthens her knowledge and skills. It is possible to use repurposed content or adapt content from other areas of your project.
For example, as I’ll discuss later in the presentation, we developed audio-visual materials for Nigerian midwives for self-learning.
It is also, possible to use this as a counseling tool to strengthen interaction between the FHW and the community. In our India and Pakistan adaptations, we explored a combination of both audio-visual materials followed by interpersonal counseling.
In both scenarios, the app’s dashboard serves as a monitoring tool, aiding program managers and policy makers. In each of our 4 adaptations, we are able to capture detailed analytics via a dynamic online dashboard on how the app is being used by the FHW with the community.
Self-Learning Tool:
Easy access to technical content
Monitoring Tool:
Provides usage statistics; client-specific counselling sessions tracked

7. Dynamic Dashboard
Client profile and data analytics available through a live dashboard
Records activities in relation to content and helps identify content that is relevant to the community
Enable program access to real time monitoring data
Helps guide program strategy and making timely intervention
Review slide bullets

8. Typical Development Process
Participatory co-development process with health workers
Pre-testing and usability workshops to revise prototype
Periodic follow-up, training, feedback sessions with health workers
Health worker feedback/suggestions built into the app
*India & Pakistan- In country ICT partner helped adapt platform to project requirements and manage troubleshooting
Workshop with participating FHWs
Monthly follow-up training sessions
Concurrent feedback received from FHWs
Building in basic case management functionality*
Further enhancements planned based on feedback
As mentioned, over the past 4 years, CCP adapted the OppiaMobile platform for use in diverse country contexts. Our approach to adaptation was largely consistent in each country:
We use the generic version of the app to develop a beta version on an Android mobile
This prototype is then shared with FLWs in a 3-day workshop.
Their usage behavior is observed. FHWs narrate their experience of using the phone and app in their work. Comments and feedback are noted.
The process is participatory and the app’s design is often aided based on FHW feedback and insights.

9. Mass Customization Nigeria- iDEA India- Gyan Jyoti Pakistan-
Bright Future
Nepal-
Smart Paramarsha
As I mentioned earlier, we developed multiple version of this app for programs in 4 countries: Nigeria, India, Pakistan and Nepal.
With each subsequent adaptation of the application, CCP expands its ability to design and develop context specific job aids and BCC tools using a single platform.
Each country uses a tailored and systematic approach towards design and content adoption.

10. Nigeria: iDEA (Interactive Distance Education App)
300 midwives under Nigerian Urban Reproductive Health Initiative (NURHI) program
Developed short videos depicting positive & negative videos counseling techniques to improve interpersonal counseling
Each course had an assessment to gauge learning
Focus Group Discussions with midwives validate use and effectiveness of approach
NIGERIA
Project- Nigerian Urban Reproductive Health Initiative (NURHI)- Ongoing
Goal- CCP discovered that the service providers in select Nigerian cities were restricting the use certain reproductive health services based on internal biases and reasons that included the client’s age, parity (number of births), their marital status, and whether their spouse had granted consent.
App purpose- NURHI launched the Interactive Distance Education Application (iDEA) system for midwives in order to provide a platform for providers to access relevant educational content and resources from Android-based smartphones or tablets to improve interpersonal communication (IPC) skills.
Innovation- This was the first time CCP used the Oppia Mobile platform for distance education with FHW. NURHI, in conjunction with a local production company, developed instructional videos with an entertainment-education approach. Each video scenario features examples to help providers recognize their biases and then address them by suggesting alternative approaches towards counseling. Each scenario has a pretest and a posttest to gauge learning.
Impact- Participants reported watching the videos and taking the quizzes several times, stating that they are good for refreshing knowledge

11. India: Gyan Jyoti (Light of Knowledge)
20 Accredited Social Health Activist (ASHAs) under Project Ujjwal ( )
Included over 30 theory based short films, providing for ASHA self-learning (mLearning) and community/ client counseling (mCounseling)
Health workers discovered new respect within community and increase engagement
Study showed that clients were 3.5 times more likely to use modern methods after being counseled with Gyan Jyoti
INDIA
Project – Project Ujjwal
Goal- CCP aimed to strengthen a weak area the provider-client IPC sessions between the FHW (Accredited Social Health Activist, ASHAs) and the community.
App purpose- Gyan Jyoti (light of knowledge) is the app developed in India. The app aimed to model key health behaviors directly to clients, which would then be followed up with an immediate IPC session with the ASHA. The app was designed to house over 30 scientifically developed SBCC films that provide expert advice, share peer group experience, provide evidence and model key health behaviors. The app also encouraged self-learning among the ASHAs and use of analytics to improve program decision-making.
Innovation- This was the first time CCP used the app for counseling, in addition to self-learning for the ASHAs. The app essentially provided a means for narrow-casting persuasive content to media dark areas.
Impact- ASHA’s using the app gained credibility and status as within their communities. A small post-only study showed that women counseled by a trained ASHA using Gyan Jyoti were 3.5times more likely to use modern family planning (compared to women counseled by an ASHA under standard counseling methods).
Costs- Estimated $20k

12. Pakistan: Roshan Mustaqbil (Bright Future)
80+ Lady Health Workers are using adapted app for mLearning and mCounseling to address entire RMNCH continuum
The Pakistan application serves a dual purpose: self-learning and client counseling on maternal and child health based on paper-based toolkit approved by local Ministry of Health
Ongoing assessment among Lady Health Workers of mCounseling component of the app
PAKISTAN
Project- Health Communication Component; Ongoing
Goal- “Roshan Mustaqbil” or Bright Future combines principles of cognitive behavioral therapy and positive deviance with persuasive audiovisual materials on maternal and child health issues to standardize counseling sessions and small group community discussions.
App purpose- The Pakistan application serves a dual purpose: self-learning and client counseling on maternal and child health. The Pakistan self-learning component built on the basic mLearning structure developed in India by carefully applying adult learning theories to develop a learning pathway for Pakistani Lady Health Workers.
Innovation- The India adaptation kickstarted this adaptation. Pakistan also using adult learning theory and the HC3 implementation kit on provide behavior change to develop scenario based content for self-learning for Lady Health Workers. Also, the Lady Health Worker Program required use of local language (Sindhi). An IT agency developed a language pack for Sindhi- meaning the content will be able to display in both Sindhi and Urdu
Impact- The project is still ongoing.
Costs- Estimated ~$14k

13. Nepal: Smart Paramarsha
180+ Facility Based Health Workers are using a scenario based mLearning app to improve their IPC techniques
Designed as a theory-based, scenario driven job aid to improve IPC among facility-based providers and FHWs
Developed in less than two weeks once content was finalized
NEPAL
Project – HC3 Nepal; Ongoing
Goal- Similarly to the Nigeria application, the Nepal team aimed to address gaps in knowledge of health areas and IPC skills , as well as reduce provide bias.
App purpose- The Nepal version of the app was designed as a theory-based, scenario driven job aid that would improve IPC among facility-based providers and FHWs related to the following topics:
45 Day Immunization
Client Choice
Dealing with Side Effects
Clearing Misconceptions
Migrants and Emergency Contraception
Innovation- The previous instances were pilots of less than 100 individuals. In Nepal, a key difference is that the app was designed for use at scale in Nepal. The team has started to deployment the app in 10 districts when the HC3 project is present.
Impact- The project is still ongoing.
Costs- Estimated $7k

14. Key Takeaways
Built for sustainability, each app was developed as part of an evolving global system that supports creation, curation, packaging and distribution of health related content for health workers.
Each country uses a tailored and systematic approach towards design and content adoption.
This process can also be engineered for institutionalization by the government to re-purpose multimedia materials for training and community education.
The system promotes collaboration of efforts by various public health program globally wherein each program builds on each other’s successes and learnings.

15. Contact: LindseyLeslie@jhu.edu
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