UPDATE – September 2016
As part of a U.K. aid-funded family planning project (“Project Ujjwal“) led by Palladium, Center for Communication Programs (CCP) developed an android-based app, called Gyan Jyoti, or “light of knowledge,” for use in the state of Bihar in India.
Project Ujjwal (2013-2015) aimed to reduce maternal deaths from unwanted pregnancies by increasing the use of family planning (FP) methods, improving birth spacing practices and preventing unsafe abortions in the states of Bihar and Odisha. To aid in this effort, the app was designed specifically for use by ASHAs- community health workers in India- who visit the homes in rural areas to promote family planning and other healthy behaviors.
Gyan Jyoti contains a plethora of persuasive audiovisual materials about family planning behaviors and modern contraceptive methods, including: entertaining and educational films, testimonials from satisfied couples who are using contraception, Q & A videos with physicians and other information that aims to dispel myths and misconceptions about modern contraception. The user interface follows a menu-driven, icon-based format for ease of use in low literacy settings. Organized by contraceptive method, clients can benefit from persuasive content and resources that are available on demand and used in combination with interpersonal communication on the part of a trained community health worker.
The application also functions as a continuous self-learning tool for the community health worker. The ultimate aim of the app is to assist community health workers and clients in deciding on a FP method during counseling sessions and accelerate the rate of adoption of spacing methods among young couples.
Timeline
Inquire
Community health workers, such as Accredited Social Health Activists, Rural/Registered Medical Practitioners, and Anganwadi Workers (ASHAs, RMPs, AWWs) and Ujjwal Saathis (Village-level entrepreneurs mobilized under Project Ujjwal) belong to the communities in which they serve.
They face capacity limitations and other challenges such as low educational qualifications, lack of technical skills related to public health and differing levels of communication and counselling skills. To more fully understand the complexity of their work, a rapid assessment was carried out by the field teams in Bihar and Odisha, which provided rich, contextual information to the Project Ujjwal team. This assessment also helped to determine the availability of multimedia / feature phones and the handset capability to support audiovisual content, revealing that in Bihar approximately 60% of the Ujjwal Saathis had either a low end multimedia / feature phones or had access to one within the close circle of friends / relatives.
In Odisha, approximately 30% of Ujjwal Saathis had access to a handset that could support screening of audio-visual content. With every second person in Bihar and Odisha having access to the mobile phone, the reach of the mobile phone far outstrips the reach of other media, especially in a media dark state like Bihar. As a result, the use of mobile phone platforms to generate demand for family planning was identified as a potentially important and impactful channel for Project Ujjwal activities.
Design the Strategy
Gyan Jyoti was designed to work in 3 key areas:
Distance education:
- Promote continued education through the easy to access self-learning tool, which provides, on-demand technical content for the community health worker
Client Counselling:
- Enhance the counselling skills of community level workers through a prepackaged menu driven application that guides the community level worker to offer customized, need tailored counselling sessions to clients
- Bring the doctor directly to the community, so that the first level of counseling is already done before clients physically go and meet the doctor
- Bridge the media gap in media dark areas by making the communication content available for immediate consumption by the community
- Aid in decision-making by the eligible couples
Monitoring:
- Monitor use of the toolkit by the ASHA for counseling
- Capture usage data on counselling sessions
Create and Test
The use of motivational and persuasive content delivered through mobile phones was tested by CCP previously in the Indian state of Uttar Pradesh under the Urban Health Initiative (UHI), a Bill & Melinda Gates funded reproductive health program. Content was loaded on SD cards and distributed to community health workers (CHWs), which they uploaded to smart phones. By using the content in their counseling sessions, the CHWs felt more confident and empowered working in their communities. In addition, community members could transfer the content to their phones via Bluetooth to show it to their spouse and start a discussion about family planning.
However, the SD card had limitations. For example, there was no way to track which videos were being shown, or to gather information about which clients adopted a method after exposure to the content. The SD card method also lacked an interactive interface, which enabled the CHW and clients to jointly select a method or a film for discussion. For insights and suggestions on how best to improve the client and CHW interaction, the India team consulted with those who had been heavily involved in the Nigeria Urban Reproductive Health Initiative (NURHI) interactive Distance Education Application (iDEA) app. Launched by NURHI in 2013, the NURHI iDEA app provides a range of instructional material with a focus on videos and exercises that help make midwives aware of and overcome their biases toward unmarried or very young clients. It was decided to expand the scope of the same platform used for the NURHI app – OppiaMobile- to develop an app tailored to the Indian context for client counseling and self-learning.
The Gyan Jyoti training process [Click on image to see it larger]
Special Features of the Gyan Jyoti Application:
- Scalable: Approach meets basic functional and user requirements for rapid adaption in any context Easy to Use: Incorporates unique artwork/logo that can be easily used to navigate the app by low literate users
- Adaptable to languages: Currently the application is available in Hindi and English and can be adapted to any language supported by Android / mobile handset being used.
- Easy to convert/edit content using Moodle for deployment on to Android based tablets or phones either over Wi-Fi or computer cable connection or via Bluetooth.
- Easy to download: Available via Google Play
- Built-in analytics so administrators can install the server for the system and track all users in a variety of ways. The data collected from Gyan Jyoti users is available for viewing via an online dashboard that displays usage data in almost real time.
- Works offline: Is specially designed for slow broadband networks and works offline, meaning no Internet connection necessary to run the app once it is fully registered- everything is stored on the device. It simply requires a periodic connection to install updates to media and upload small (<10K) usage statistics files for monitoring purposes
- Open source: Android based mobile learning application; no licensing requirements provide health information on demand:
- Films including role model films, behavioural films, TV ads and doctor’s films addressing methods such as intrauterine device (IUD), condom, oral contraceptive pills (OCP), injectable, female sterilization, male sterilization, medical abortion and emergency contraceptive pills (ECP), were loaded onto the phones. These films help clients understand the benefits and challenges associated with each method. They also serve to motivate the clients to adopt a method.
- mLearning content is available so that the community health workers can build their skills in Interpersonal communication, GATHER counselling method and FAQs and answers on FP methods
[Click on image above to see it larger]
Mobilize and Monitor
Mobilization
As part of Project Ujjwal, community health workers carried the phones into the homes of eligible couples in rural Bihar. Although workers have varying levels of education, Gyan Jyoti allowed them to become mobile “information hubs” for community members considering a family planning method and it offered motivation to those who were hesitant or had doubts or concerns about specific methods. The app supplied ready access to technical information on family planning methods. It also helped dispel myths about methods and helped to break down social taboos, thus helping the couples to overcome social, cultural and personal barriers in adoption of modern contraceptives.
Health workers say the app gave them confidence and increased their credibility in communities where fears and myths about side effects are a formidable barrier to contraceptive use.
Monitoring
A process for capturing user feedback was put in place to modify the application and make it user friendly. Part of this process included a design workshop with 14 ASHAs which resulted in a number of specific changes to the app.
Examples of these changes are:
- Realigned counselling content allowing for easy access to the video content: the life-stage wise segregation of content which had been meant to aid the ASHA in offering need-specific counselling was also found to hinder easy retrieval of videos as these were embedded under 2 layers
- Removal of the pre and post tests that were built into the app as it was found that the ASHAs were unable to administer them accurately to capture the intended information.
- Simplified screens and intake forms (i.e. client registration screen) so the ASHA could quickly move on to counseling clients
Once the updates were completed, ASHAs continued to test the application on smart phones, and used it during their home visits with clients. The concurrent feedback received from ASHAs was sought to improve the app and guide future enhancements. IT related issues observed during the field-testing were also addressed.
Below: Gyan Jyoti app page on Google Play [click to see larger]
Evaluate and Evolve
In May 2015, five months after the app was made available to the ASHAs, a random sample of 406 women from two districts with similar characteristics were selected to study the effect of the app on provider and client behavior. In one district of Bihar, smartphones loaded with the Gyan Jyoti app were given to 14 ASHAs, while in another comparable district another 14 ASHAs were supplied with low-tech SD cards containing the same AV content.
Between the two districts, each set of ASHAs visited an estimated 1,400 rural women. Those ASHAs who had the SD card could show the videos, but did not have the benefit of customizing their interaction. The ASHAs with the smartphone app were able to customize their family planning counseling, showing videos most appropriate to answer each woman’s particular questions. In addition, the ASHAs using the app were also able to share the films via Bluetooth to their clients, enabling the women to show it to their husbands or mothers-in-law at a later time. The study data showed that clients who watched videos were 4.5 times more likely to use modern contraceptive methods than those who did not.
In addition, the study found that:
- 22% of women who were counseled with the app were using modern contraception such as IUDs, oral contraceptive pills and injectable contraception at the end of the study period
- 13% of the women were using modern contraception in the district without the app
- 17% of the women who had access to the smartphone app watched some of the videos and 2.4% of those who only had access to the SD card watched the videos
- Of the 75 women in the intervention district who were using modern contraceptive methods at the end of the study period, three-quarters of them had interacted with the app
- Women who were visited by an ASHA during the study period were 1.9 times more likely to be using modern contraceptive methods
- Visits by ASHA workers were up 56% in the intervention district compared to 47% in the SD card district
Gyan Jyoti app available on Google Play – https://play.google.com/store/apps/details?id=org.ujjwal.saathi.oppia.mo…
Lessons Learned
ASHAs were enthusiastic in their use of Gyan Jyoti during home counseling.
The user-friendly interface, co-development of the app and expanded opportunities for client interactivity and interpersonal communication may have contributed to the positive findings from the proof of concept study. The SD card had limitations as there was no way for the team to track which videos were being shown, or to gather information about which clients adopted a method after exposure to the content.
Planning for the Future
While this mobile-based entertainment education application currently focuses on family planning, there is the capacity to expand this to cover the entire RMNCH+A framework that is being used by the National Health Mission in India.
Gyan Jyoti also has the potential to integrate with service delivery platforms to provide case specific counseling and enable client tracking, thus enhancing follow-up systems and create synergies at various levels of service delivery.
Further, CCP has been continually expanding and testing this platform to meet new demands: In 2015, an adaptation of Gyan Jyoti was designed for Pakistani Lady Health Workers working on maternal and child health issues in rural Sindh Province.
All photos: Credit: Sanjanthi Velu
Date of Publication: April 20, 2022
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