UNICEF Somalia (Birungi, Anand, Chatterjee, Alam, Mutai, Kemoh); Oxfam Somalia (Kinyanjui)
"Overall, the SMS approach did reach a large number of people in a short time compared to conventional methods like interpersonal communication, which in this case would have increased security risks for the community mobilisers."
This paper presents key findings from an evaluation of a project on the use of mobile phones in the prevention of polio in Somalia with the purpose of highlighting key learning that can be used to design, implement, and scale up similar projects in conflict-affected countries.
Implemented by the United Nations Children's Fund (UNICEF) in partnership with Oxfam GB and a local partner, Hijra, the project was designed in response to a large wild poliovirus (WPV) outbreak that paralysed 199 children and young adults in Somalia, 2013-2014. Despite significant investments in both routine and house-to-house campaign-based immunisation since the outbreak, "security challenges make it difficult for house-to-house mobilisation in several areas, especially among scattered households in rural areas, districts that are inaccessible due to insurgency, coastal regions where piracy is an issue, and amongst nomadic groups. Similarly, the monitoring of vaccination and social mobilisation in these areas is difficult because of the lack of roads and insecurity."
In considersation of this context, the project had two components: (i) a pre-emptive community education programme delivered through interactive short message service (SMS), or text messaging, on polio prevention, and (ii) distribution of water and sanitation items through SMS voucher redemption. The two components were designed and delivered through an Oxfam-run mobile phone platform called mLink, which uses an interactive mobile phone application to engage communities. It is cloud-hosted and does not require any installations to be done on phones. It has proven to be a cost-effective mechanism to increase reach and access that is easy and cheap to scale, since it uses the mobile phones that people already have. Real-time monitoring (RTM) was used to monitor interventions in areas which were inaccessible by UNICEF staff. RTM is done through the "RapidPro platform to reduce programmatic, operational and reputational risks while improving the delivery and quality of services through enhanced end-use monitoring of supplies, real-time tracking of key indicators, and two-way communication with beneficiaries. RapidPro is an open-source SMS-based (text message) platform that manages data collection, complex workflows, and group coordination using basic mobile phones." The main objectives of the intervention/partnership were to: (i) reach at least 1,000,000 children and women with health education messages on polio and water, sanitation, and hygiene (WASH), (ii) increase their knowledge of the relationship between polio and safe hygiene practices, and (iii) distribute 50,000 WASH non-food item (NFI) supplies to vulnerable beneficiaries
The evaluation methodology included: a household survey of 423 randomly selected men and women; focus group discussions (FGDs) with 40 men, women, youth, and traders; and key informant interviews with 10 staff members of Oxfam GB, UNICEF, and Hijra. The key evaluation questions were on relevancy, effectiveness, efficiency, and scalability.
Findings from the evaluation showed that the total number of phone users reached by the campaign was 104,358 - exceeding the target of 100,000. (The goal was to reach 1 million people; a feasibility study connected to a previous Oxfam project revealed that, in Somalia, on average 10 people share the benefit of information delivered to one phone). Of the phone users reached, a total of 89,760 (86%) completed the health education sessions. There was some evidence that the sessions had an impact in terms of knowledge gained: While baseline data showed that people previously thought polio was airborne, 99.8% respondents were able to link polio to water and sanitation at the end of the project. Also, RTM was piloted in the North East and North West Zones of Somalia, where 3 SMS questions were sent to 1,123 community mobilisers (196 in Somaliland and 927 in Puntland) on the last day of the polio campaign held in February 2015. With regard to RTM, 78 community mobilisers from Somaliland and 278 community mobilisers from Puntland responded to the SMS questions, indicating a 32% response rate.
Among the challenges to using SMS platforms: "Somalia is largely an oral society, meaning that people are accustomed to communicating orally or verbally – news commonly spreads through word of mouth, and people want to talk and listen. Texting is therefore not common as an interactive communication approach, and it requires a behaviour shift." With regard to uptake of the technology, some FGD respondents reported being illiterate and busy with competing priorities. This made it difficult for them to participate in the sessions. For the RTM, respondents did not appreciate having to pay for SMS, leading some of them to drop out of the programme. Charges can therefore be a hindrance to using the SMS platforms. In terms of the distribution of NFIs to the participants who completed the health education, there were complaints that the distances to the NFI traders and distributers was long, so some people did not pick up the items.
The research project demonstrated that mobile phones offer an alternative platform for reaching inaccessible populations with health messages, and the mVoucher system for distribution of NFIs has the potential to make distribution more convenient to beneficiaries. However, "[m]ore investment is required in terms of community involvement and sensitisation, capacity building of the partners involved, partnership strengthening, and stakeholder engagement."
Editor's note: This paper was submitted to the new open access journal Global Health Communication (GHC) as part of a United States Agency for International Development (USAID)-funded initiative to ensure that academics and practitioners from a range of countries, including those facing the greatest polio and routine immunisation challenges, are supported in getting their research peer reviewed, published, and widely disseminated. Although not all submitted papers were accepted for publication in the GHC journal, The Communication Initiative (a partner in this initiative) worked with some of the authors to adapt their papers for publication on The CI website.
Email from Julianne Birungi to Soul Beat Africa on May 27 2016. Image credit: Abdirahim M. Abdurahman, Hijra