This Social and Behavior Change Communication (SBCC) Spotlight on Health COMpass from the Health Communication Capacity Collaborative (HC3) explores the process and impact of developing an android-based phone app called Gyan Jyoti ("light of knowledge") designed to generate family planning (FP) demand in the states of Bihar and Odisha in India. It was created as part of Project Ujjwal (2013-2015), which was led by Palladium and the Johns Hopkins University Center for Communication Programs (CCP), with United Kingdom (UK) Department for International Development (DFID)/UKaid funding. The project aimed to reduce maternal deaths from unwanted pregnancies by increasing the use of FP methods, improving birth spacing practices, and preventing unsafe abortions.
Gyan Jyoti was designed specifically for use by community health workers (CHWs), who visit homes in rural areas to promote FP and other healthy behaviours. Accredited Social Health Activists, Rural/Registered Medical Practitioners, and Anganwadi Workers (ASHAs, RMPs, AWWs) and Ujjwal Saathis (village-level entrepreneurs mobilised 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. With every second person in Bihar and Odisha having access to the mobile phone, it was found that the reach of the mobile phone far outstrips the reach of other media, especially in a media-dark state like Bihar. 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, or UHI (see Related Summaries, below). Content was loaded on Secure Digital (SD) cards and distributed to 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 [FP]."
The open source app, available on Google Play, contains a variety of persuasive audiovisual (AV) materials about FP behaviours 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. Organised by contraceptive method, the app contents are available on demand and used in combination with interpersonal communication on the part of a trained CHW. Gyan Jyoti also functions as a self-learning tool for the CHW so they can build their skills in interpersonal communication, the GATHER counselling method, and FAQs and answers on FP methods. It is designed to be: scalable, easy to use, adaptable to any language supported by the android/mobile handset being used, easy to convert/edit content, and easy to download. It has 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. Gyan Jyoti also works offline once it is fully registered; it simply requires a periodic connection to install updates to media and upload small (<10K) usage statistics files for monitoring purposes.
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 sterilisation, male sterilisation, medical abortion, and emergency contraceptive pills (ECP) were loaded onto the ASHAs' 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. Click here to access a YouTube playlist; see below for "Project Ujjwal mHealth Toolkit: SD Card Demo Film".
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. Then, as part of Project Ujjwal, the ASHAs 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."
In May 2015, 5 months after the app was made available to the ASHAs, a random sample of 406 women from 2 districts with similar characteristics were selected to study the effect of the app on provider and client behaviour. 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 2 districts, each set of ASHAs visited an estimated 1,400 rural women. The ASHAs with the smartphone app were able to customise their FP 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 found that clients who watched videos were 4.5 times more likely to use modern contraceptive methods than those who did not. In addition,
- 17% of the women who had access to the smartphone app watched some of the videos in comparison to 2.4% of those who only had access to the SD card.
- 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, whereas 13% of the women were using modern contraception in the district without the app.
- Visits by ASHA workers were up 56% in the intervention district compared to 47% in the SD card district.
- Women who were visited by an ASHA during the study period were 1.9 times more likely to be using modern contraceptive methods.
- 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.
However, 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.
CCP has been continually expanding and testing this platform to meet new demands. For example, in 2015, an adaptation of Gyan Jyoti was designed for Pakistani Lady Health Workers (LHWs) working on maternal and child health issues in rural Sindh Province.
Email from HC3 to The Communication Initiative on July 13 2016. Image credit: Sanjanthi Velu