Using behavioural design and theories of change to integrate communication solutions into health systems in India: evolution, evidence and learnings from practice.

Between 2011 and 2019, an integrated communication programme to address reproductive, maternal, neonatal and child health was implemented in the Indian state of Bihar. Along with mass media, community events and listening groups, four mobile health services were co-designed with the government of Bihar. These were Mobile Academy-a training course for frontline health workers (FLHWs) supporting them as the last mile of the health system; Mobile Kunji-a job aid to support FLHWs' interactions with families; Kilkari-a maternal messaging service delivering information directly to families' mobile phones, encouraging families to seek public health services through their FLHWs; and GupShup Potli-mobile audio stimulus used by FLHWs in community events. While Mobile Kunji and GupShup Potli scaled to other states (two and one, respectively), neither was adopted nationally. The Government of India adopted Kilkari and Mobile Academy and scaled to 12 additional states by 2019. In this article, we describe the programme's overarching person-centred theory of change, reflect on how the mHealth services supported integration with the health system and discuss implications for the role of health communication solutions in supporting families to navigate healthcare systems. Evaluations of Kunji, Academy and GupShup Potli were conducted in Bihar between 2013 and 2017. Between 2018-2020, an independent evaluation was conducted involving a randomised controlled trial for Kilkari in Madhya Pradesh; qualitative research on Kilkari and Academy and secondary analyses of call record data. While the findings from these evaluations are described elsewhere, this article collates key findings for all the services and offers implications for the role digital and non-digital communication solutions can play in supporting joined-up healthcare and improving health outcomes.

Ten lessons learnt: scaling and transitioning one of the largest mobile health communication programmes in the world to a national government.

There has been exponential growth in the numbers of 'digital development' programmes seeking to leverage technology to solve systemic challenges. However, despite promising results and a shift from pilots to scale-ups, many have failed to realise their full potential. This paper reflects on lessons learnt from scaling and transitioning one of the largest mobile health programmes in the world to the Indian government. The complementary suite of services was designed by BBC Media Action to strengthen families' reproductive, maternal, neonatal and child health behaviours. Mobile Academy was a training course to refresh frontline health workers' (FLHWs) knowledge and improve their interpersonal communication skills. Mobile Kunji was a job aid to support FLHWs' interactions with families. Kilkari delivered weekly audio information to families' phones to reinforce FLHWs' counselling. As of April 2019, when Mobile Academy and Kilkari were transitioned to the government, 206 000 FLHWs had graduated and Kilkari had reached 10 million subscribers. Lessons learnt include the following: (1) private sector business models are challenging in low-resource settings; (2) you may pilot 'apples' but scale 'oranges'; (3) trade-offs are required between ideal solution design and affordability; (4) programme components should be reassessed before scaling; (5) operational viability at scale is a prerequisite for sustainability; (6) consider the true cost of open-source software; (7) taking informed consent in low-resource settings is challenging; (8) big data offer promise, but social norms and SIM change constrain use; (9) successful government engagements require significant capacity; (10) define governance structures and roadmaps up front.

Implementing health communication tools at scale: mobile audio messaging and paper-based job aids for front-line workers providing community health education to mothers in Bihar, India.

INTRODUCTION: As part of an investment by the Bill & Melinda Gates Foundation to support the Government of Bihar to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide, BBC Media Action implemented multiple communication tools to support front-line worker (FLW) outreach. We analyse the impacts of a package of mHealth audio messaging and paper-based job aids used by FLWs during government-sponsored village health, sanitation and nutrition days (VHSNDs) on knowledge and practices of childbearing women across the RMNCHN continuum of care. METHODS: Data from two surveys collected between July and September 2016 were analysed using logistic regression to compare health-related knowledge and behaviours between women who had been exposed at VHSNDs to the mHealth GupShup Potli (GSP) audio recordings or interpersonal communication (IPC) tools versus those who were unexposed. RESULTS: Exposure to GSP recordings (n=2608) was associated with improved knowledge across all continuum-of-care domains, as well as improved health-related behaviours in some domains. The odds of having taken iron-folic acid (IFA) tablets were significantly higher in exposed women (OR 1.5, 95% CI 1.1 to 2.2), as was contraceptive use (OR 2.0, 95% CI 1.2 to 3.2). There were no differences in birth preparedness or complementary feeding practices between groups. Exposure to IPC paper-based tools (n=2002) was associated with a twofold increased odds of IFA consumption (OR 2.3, 95% CI 1.7 to 3.2) and contraceptive use (OR 1.8, 95% CI 1.2 to 2.8). Women exposed to both tools were generally at least twice as likely to subsequently discuss the messages with others. CONCLUSION: BBC Media Action's mHealth audio messaging job aids and paper-based IPC tools were associated with improved knowledge and practices of women who were exposed to them across multiple domains, suggesting their important potential for improving health outcomes for beneficiaries at scale in low-resource settings. TRIAL REGISTRATION NUMBER: NCT02726230.

Entertainment-Education Campaigns and COVID-19: How Three Global Organizations Adapted the Health Communication Strategy for Pandemic Response and Takeaways for the Future.

COVID-19 created a substantial set of challenges for health communication practitioners in the process of planning, implementing, and evaluating entertainment-education (EE) campaigns. EE is a theory and evidence-based communication strategy that employs entertainment media for educational messaging. Here, we briefly review EE campaigns in response to previous health emergencies and present three cases of EE responses to the COVID-19 pandemic from leading global organizations (PCI Media, BBC Media Action, and Sesame Workshop). Responses ranged from adaptation and re-distribution of existing content to creating new content under social-distancing restrictions and utilizing transmedia. These cases demonstrate that EE initiatives responding to future pandemics may be well served by starting with existing infrastructure to quickly build capacity, support, and trust; working with partners to tailor programs to the local context; and continuing to focus on good storytelling while simultaneously considering evolving media formats and theory.

Impact of mHealth interventions for reproductive, maternal, newborn and child health and nutrition at scale: BBC Media Action and the Ananya program in Bihar, India.

BACKGROUND: Mobile health (mHealth) tools have potential for improving the reach and quality of health information and services through community health workers in low- and middle-income countries. This study evaluates the impact of an mHealth tool implemented at scale as part of the statewide reproductive,maternal, newborn and child health and nutrition (RMNCHN) program in Bihar, India. METHODS: Three survey-based data sets were analysed to compare the health-related knowledge, attitudes and behaviours amongst childbearing women exposed to the Mobile Kunji and Dr. Anita mHealth tools during their visits with frontline workers compared with those who were unexposed. RESULTS: An evaluation by Mathematica (2014) revealed that exposure to Mobile Kunji and Dr. Anita recordings were associated with significantly higher odds of consuming iron-folic acid tablets (odds ratio (OR) = 2.3, 95% confidence interval (CI) = 1.8-3.1) as well as taking a set of three measures for delivery preparedness (OR = 2.8, 95% CI = 1.9-4.2) and appropriate infant complementary feeding (OR = 1.9, 95% CI = 1.0-3.5). CARE India's Community-based Household Surveys (2012-2017) demonstrated significant improvements in early breastfeeding (OR = 1.64, 95% CI = 1.5-1.78) and exclusive breastfeeding (OR = 1.46, 95% CI = 1.33-1.62) in addition to birth preparedness practices. BBC Media Action's Usage & Engagement Survey (2014) demonstrated a positive association between exposure to Mobile Kunji and Dr. Anita and exclusive breastfeeding (58% exposed vs 43% unexposed, P < 0.01) as well as maternal respondents' trust in their frontline worker. CONCLUSIONS: Significant improvements in RMNCHN-related knowledge and behaviours were observed for Bihari women who were exposed to Mobile Kunji and Dr. Anita. This analysis is unique in its rigorous evaluation across multiple data sets of mHealth interventions implemented at scale. These results can help inform global understanding of how best to use mHealth tools, for whom, and in what contexts. STUDY REGISTRATION: ClinicalTrials.gov number NCT02726230.

Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of Ananya.

In 2010, the Bill and Melinda Gates Foundation (BMGF) partnered with the Government of Bihar (GoB), India to launch the Ananya program to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes. The program sought to address supply- and demand-side barriers to the adoption, coverage, quality, equity and health impact of select RMNCHN interventions. Approaches included strengthening frontline worker service delivery; social and behavior change communications; layering of health, nutrition and sanitation into women's self-help groups (SHGs); and quality improvement in maternal and newborn care at primary health care facilities. Ananya program interventions were piloted in approximately 28 million population in eight innovation districts from 2011-2013, and then beginning in 2014, were scaled up by the GoB across the rest of the state's population of 104 million. A Bihar Technical Support Program provided techno-managerial support to governmental Health as well as Integrated Child Development Services, and the JEEViKA Technical Support Program supported health layering and scale-up of the GoB's SHG program. The level of support at the block level during statewide scale-up in 2014 onwards was approximately one-fourth that provided in the pilot phase of Ananya in 2011-2013. This paper - the first manuscript in an 11-manuscript and 2-viewpoint collection on Learning from Ananya: Lessons for primary health care performance improvement - seeks to provide a broad description of Ananya and subsequent statewide adaptation and scale-up, and capture the background and context, key objectives, interventions, delivery approaches and evaluation methods of this expansive program. Subsequent papers in this collection focus on specific intervention delivery platforms. For the analyses in this series, Stanford University held key informant interviews and worked with the technical support and evaluation grantees of the Ananya program, as well as leadership from the India Country Office of the BMGF, to analyse and synthesise data from multiple sources. Capturing lessons from the Ananya pilot program and statewide scale-up will assist program managers and policymakers to more effectively design and implement RMNCHN programs at scale through technical assistance to governments.