mHealth intervention ImTeCHO to improve delivery of maternal, neonatal, and child care services-A cluster-randomized trial in tribal areas of Gujarat, India

Background The coverage of community-based maternal, neonatal, and child health (MNCH) services remains low, especially in hard-to-reach areas. We evaluated the effectiveness of a mobile-phone-and web-based application, Innovative Mobile-phone Technology for Community Health Operations (ImTeCHO), as a job aid to the government's Accredited Social Health Activists (ASHAs) and Primary Health Center (PHC) staff to improve coverage of MNCH services in rural tribal communities of Gujarat, India. Methods and findings This open cluster-randomized trial was conducted in 22 PHCs in six tribal blocks of Bharuch and Narmada districts in India. The ImTeCHO mobile-phone-and web-based application included various technology-based job aids to facilitate scheduling of home visits, screening for complications, counseling during home visits, and supportive supervision by PHC staff. Primary outcome indicators were a composite index calculated based on coverage of important MNCH services and coverage of at least two home visitations by ASHA within the first week of birth. Primary analysis was intention to treat (ITT). Generalized Estimating Equation (GEE) was used to account for clustering. Eleven PHCs each were randomly allocated to the intervention (280 ASHAs, population: 234,134) and control (281 ASHAs, population: 242,809) arms. The intervention was implemented from February, 2016 to January, 2017. At the end of the implementation, 6,493 mothers were surveyed. Most of the surveyed women were tribal (5,571, 85.8%), and reported having a government-issued certificate for living below poverty line (4,916, 75.7%). The coverage of at least two home visits within first week of birth was 32.4% in the intervention clusters compared to 22.9% in the control clusters (adjusted effect size 10.2 [95% CI: 6.4, 14.0], p < 0.001). Mean number of home visits within first week of birth was 1.11 and 0.80 for intervention and control clusters, respectively (adjusted effect size 0.34 [95% CI: 0.23, 0.45], p < 0.001). The composite coverage index was 43.0% in the intervention clusters compared to 38.5% (adjusted effect size 4.9 [95% CI: 0.2, 9.5], p = 0.03) in the control clusters. There were substantial improvements in coverage home visits by ASHAs during antenatal period (adjusted effect size 15.7 [95% CI: 11.0, 20.4], p < 0.001), postnatal period (adjusted effect size 6.4, [95% CI: 3.2, 9.6], p <0.001), early initiation of breastfeeding (adjusted effect size 7.8 [95% CI: 4.2, 11.4], p < 0.001), and exclusive breastfeeding (adjusted effect size 13.4 [95% CI: 8.9, 17.9], p < 0.001). Number of infant and neonatal deaths was similar in the two arms in the ITT analysis. The limitations of the study include potential risk of inaccuracies in reporting events that occurred during pregnancy by the mothers and the duration of intervention being 12 months, which might be considered short. Conclusions In this study, we found that use of ImTeCHO mobile- and web-based application as a job aid by government ASHAs and PHC staff improved coverage and quality of MNCH services in hard-to-reach areas. Supportive supervision, change management, and timely resolution of technology-related issues were critical implementation considerations to ensure adherence to the intervention. Author summaryWhy was this study done? Delivery of community-based maternal, neonatal, and child health (MNCH) services can improve health outcomes and reduce preventable infant deaths. To improve the coverage of proven MNCH services, a new cadre of village-based frontline workers, called Accredited Social Health Activists (ASHAs), was introduced by the government of India in 2005. However, the coverage and quality of MNCH services delivered by ASHAs remains low, especially in hard-to-reach tribal areas. Mobile-phone-technology-based health (mHealth) solutions are promising, innovative strategies with the potential to improve performance of frontline health workers in controlled settings. However, there is a lack of robust evidence about the effectiveness of mHealth solutions implemented within the public health system as a job aid to frontline health workers towards improving coverage of MNCH services. What did researchers do and find? Twenty-two Primary Health Centers (PHCs) were randomly allocated to usual care from public health providers from the government with (11 PHCs, 280 ASHAs, population: 234,134) or without (11 PHCs, 281 ASHAs, population: 242,809) an mHealth intervention. The mHealth intervention included a package of various mobile-phone-technology-based job aids to facilitate longitudinal tracking, scheduling of health services, screening for complications, counseling for behavior change communication, and real-time monitoring and supportive supervision by supervisory staff at PHCs. Twelve months after the implementation, mothers were surveyed. We found that coverage and quality of most of the MNCH services were significantly higher among PHCs that were served by ASHAs who used mHealth as a job aid compared to those who did not. The coverage of at least two home visits within first week of birth was 32.4% in the mHealth intervention group, compared to 22.9% in the control group. A composite index, which was calculated based on coverage of multiple key MNCH services, was 43.0% in the mHealth intervention group compared to 38.5% in the nonintervention group. The ASHAs regularly used and adhered to the mHealth intervention; however, its use was low among the PHC staff. What do these findings mean? To our knowledge, this is the one of the first studies of its kind that assessed effectiveness of multiple mHealth job aids implemented in a low- and middle-income country (LMIC) through frontline health workers in an existing public health system throughout the continuum of care to improve wide range of MNCH outcomes among hard-to-reach populations using a robust research methodology. Adequate supportive supervision, change management, and ongoing technology assistance is crucial to ensure satisfactory adherence to the intervention. Our findings support the scale-up of mobile-phone-technology-based interventions as a job aid to frontline health workers to improve health outcomes.