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5 steps to enable health workers to better meet the needs of hard-to-reach communities

2019-04-05T14:05:00+00:00

As World Health Day approaches, and as we look towards the first-ever UN High-Level Meeting on Universal Health Coverage later this year, we’re sharing insights from ��tv Media Action’s work to help health workers and communities work better together to build a healthier world.

In low-income countries in Africa and Asia, many health systems are staffed by community health workers. In Nepal they are known as Female Community Health Volunteers, in Ethiopia, Health Extension Workers, while in India and Bangladesh they are generally known as Frontline Health Workers.

Whilst the names may differ, most are women, most work in remote areas, and many are volunteers. They play a vital role connecting people to, and sometimes providing, basic primary care; referring patients to clinical services and motivating families to adopt heathier practices.

All are tasked with communicating about health, but often they lack sufficient training or engaging communication tools that would help them do this more effectively.

This is where ��tv Media Action comes in. Over the last 10 years we’ve been supporting community health workers to better meet the needs of their communities. These are five important things we have learned in the process:

First, understand the world health workers live and work in

In Nepal, access to communities can be extremely challenging for Female Community Health Volunteers (FCHVs) due to large distances and difficult terrain between communities and health centres in rural areas. What’s more, FCHVs are often balancing their responsibilities with looking after family and, as many of them are volunteers, trying to earn an income.

Whilst access to mobile networks and internet is increasing, literacy rates remain low in rural areas and our research shows that some communities feel FCHVs should know more than they currently do. It became evident that updated training and tools that fit with the practicalities of FCHVs’ day-to-day lives and the changing community needs would help.

Most FCHVs have access to a basic mobile phone and mobile network, so we’re now working with our partners to explore how training and tools for basic mobile phones will help them to carry out their duties in remote areas. We’re also developing creative printed materials to support their interaction with people of all literacy levels in their communities.

In a similar project in Bangladesh, we discovered that health workers were using heavy, cumbersome flip charts to visit their clients in urban slums, so we developed a mobile app to help them undertake their roles more effectively.

“Now I’m getting all the topics by using one app which is not possible with other tools (flash cards, flip charts, leaflets). I can deliver all relevant information by the app which was difficult for me before” said one community health worker who frequently used the app.

Second, use human centred design and build partnerships

In rural India, the catalyst for the development of our highly successful Mobile Kunji and Mobile Academy projects was women’s lack of access to traditional mass media platforms. At the start of this work, our formative research showed that only a few women watched television or listened to the radio, however 82% had access to some form of basic mobile phone. So, rather than setting up a parallel system, ��tv Media Action leveraged the one available.

Using human centred design, our India team created content that worked on basic mobile phones and suited how health workers used them – to make and receive calls only. We created Mobile Academy, a training course for health workers, which is delivered through mobile audio messages, whilst Mobile Kunji is a set of visual cards and accompanying mobile audio messages that health workers can use during visits with families. Using these services and tools, our research has shown that health workers are able to better reach, engage, and influence families to improve their health.

These projects have not only worked, but they’ve shown sustainability. By working in partnership with the state governments in Bihar, Odisha and Uttar Pradesh, we’ve trained 263,000 health workers so far on Mobile Kunji and about 260,000 people have completed the Mobile Academy course.

Mobile Academy is now active in 13 states and we recently transitioned responsibility for the service to the Indian Government to continue its vital work long into the future.

Third, create relatable and accurate content to help to build trust

In Bangladesh we learnt that community health workers were struggling to communicate effectively about sexual health to young women and men, which limited the impact of their advice.

So we developed a smartphone app. It shows Dr Natasha, a real doctor, talking about some of the key sexual, reproductive, and maternal and child health issues their clients were facing. By using appropriate language tailored to their audiences, we made sure the content was relatable, accessible, and engaging – which mattered especially in areas with low literacy levels.

Our research showed us that health workers felt more trusted by their clients and were more successful in persuading them to adopt healthier practices, such as attending antenatal care visits. As one of the health workers described, “Most of my clients were not interested in listening to my suggestions before using the job aid. But now they are convinced as they see there is symmetry between Dr Natasha’s information and my own”.

We found the app also helped to give them credibility to dispel myths around issues such as contraception and family planning.

Fourth, go beyond training on health topics and train on how to communicate

Community health workers cover a wide variety of health issues on their visits. Our research often reveals the benefits of refreshing or deepening their knowledge, but also of them gaining new skills on how to communicate within a family setting. We found in remote parts of Ethiopia, communicating with the men in the family is often overlooked because family health is still seen as a woman’s responsibility.

So we ran training for Health Extension Workers which focused on how to create safer feeding and playing spaces for children under three, during which participants learned how to communicate effectively with, and actively involve, both women and men in the families.

We found role play really helped during training because it encouraged Health Extension Workers to practise how to have compelling two-way conversations.

And finally, break down the barriers between communities and health workers

Mistrust and suspicion between communities and health workers is common in many of the places we work. Through our research, we often hear about these difficulties and then aim to create safe spaces for communities and health workers to come together, get to know each other, and discuss often sensitive issues.

In Nigeria we facilitate discussions around polio vaccinations and routine immunisation as part of our community drama radio recordings which are performed in front of a live audience. And, working with different partners, we accompany women during antenatal care check-ups to record what happens. By sharing real-life experiences in our radio programmes, it helps to build understanding and trust in health services amongst the public.

In Tanzania, we trained and worked with radio partners to facilitate lively community events that were recorded and broadcast in weekly radio shows to audiences across the country. The events were designed to build understanding about maternal and newborn health issues and encourage interaction with health workers. By facilitating conversations, we found people gained understanding and confidence to access health services. We also saw increased male engagement in maternal and newborn health care.

Looking forward

In summary, we’ve learnt to not only help build the skills and confidence of community health workers, but also to help improve engagement between them and members of their communities. Through creative communication and human centred design, it is possible to create more effective tools fit for the difficult environments health workers operate in. And in doing so, we’re able to help health workers and communities work better together.

Informed by our experience, ��tv Media Action plans to continue this important work towards the UHC2030 global movement, to build stronger health systems for people around the world.

Emebet Wuhib-Mutungi and Genevieve Hutchinson
Senior Health Advisors for ��tv Media Action
On Twitter: @ewuhib / @genevieveh77

The projects featured in this blog were carried out in conjunction with: national government ministries and departments of health, DFID, UNICEF, The Gates Foundation, UNFPA, Options, Abt Associates, Viamo, Care International, the Grameen Foundation and our media partners.

Using human-centred design to achieve your goals

2017-11-07T13:26:06+00:00

This blog was originally posted on India Development Review (IDR’s) Practice blog

One can’t talk about design without quoting Steve Jobs.

“Design is a funny word," he said, "Some people think design is how it looks. But of course, if you dig deeper, it’s really how it works.” He hit the bullseye as always. Look at the success of design-driven companies like AirBnB and Pinterest, or even digital giants like Google, eBay and LinkedIn, who have invested in the design of more engaging and differentiated user experiences.

During the last couple of years, human-centred design has acquired a somewhat elusive and awe-inspiring reputation among donors and implementers. Everyone wants it, yet struggles to see how it can fit in with achieving development goals.

At ��tv Media Action, we use the power of media and communication to create social and behaviour change. For a lot of our work, like the mhealth services Mobile Kunji, Mobile Academy and Kilkari, we have been using human-centred design, long before it became a term de jour! “Admittedly I flip between being overjoyed that many in the development community have suddenly bought into design thinking, and being frustrated that this is seen as something new,” says my colleague Yvonne MacPherson, ��tv Media Action’s US director.

Now that human-centred design is trendy, we need to make sure it is not treated as a separate, add-on activity or process. It is integral to “doing development”. Donors are now putting out separate calls for proposals just for human-centred design, presumably to support other implementation efforts.

This then begs the question, why are all implementers not using human-centred design principles in their work? And if they are not, what could be the reasons—lack of resources, time or access to technology? Which brings me to the biggest myth around human-centred design—that it can only be used to create digital or tech solutions. Which is why, I will use a no-tech (not even low-tech!) innovation to talk you through the process. This is a tool we have created for pregnant women in Bihar, where 60% of women aged between 15 and 59 years suffer from anaemia, the silent killer.

Five tenets of human-centred design

1. Empathise/immerse – to create meaningful innovations, know your users and care about their lives

The problem with most pregnant women in Bihar is that even though they know what to do, compliance with whatever has been prescribed or is necessary is a challenge. Pregnant women not completing the full course of iron folic acid (IFA) tablets is a major issue. They start and then stop because of side effects. They also have no idea why this supplement is so critical because they have no understanding of the connection between their blood count and the baby growing inside them.

2. Define/mine the insight – frame the right problem and dig out the right insight to create the right solution

So what would help women stay the course? Creating risk perception. A mother’s body is like a factory that must produce blood for a healthy baby. Can she afford not to do this ‘most significant’ bit for her unborn child? Could we therefore ‘re-engineer a blood factory’?

3. Ideate – there’s no ‘right’ idea, generate many

How to show a rural woman (without access to ultrasonography) the baby growing inside her? How to explain visually the blood factory– the link between mother and baby through blood? How to use emotion to ensure compliance? How to use language moored in popular culture to convey a simple doable action? How to nudge the woman to take the same action every day over 180 days?

4. Prototype – build to think and test to learn

We created a paper-based prototype in three parts called Khoon ka Rishta (bloodline). The frontline health worker (FLW) would use one part to explain to women in a group how IFA tablets help create the bloodline between mother and child, and how missing even one tablet could actually break that line.

The second part of the paper, to be kept by the mother, carried an illustration: the outline of a baby’s body, with teardrop-shaped gaps inside. This paper prototype also included the entire course of IFA tablets and strips of teardrop-shaped adhesive bindis, to fit the gaps.

See below.

As the mother would take a tablet, she would use the red bindi to cover up those gaps in the baby’s body. And as she would complete her course of 180 tablets, she would watch this baby becoming whole.

The third part was a card with a congratulatory message using the same teardrop graphic.

5. Test – learn about your solution and your user

What did we learn? Both types of user - frontline workers and pregnant women, understood and liked the tool. But it needed to be simplified. So, we eliminated some details, redesigned a few and made instructions crisper and clearer.

Women engaged with the tool at an emotional level—it provided a visual and vivid reminder of a deep connection: “I’m taking a tablet and that’s helping my baby form and be whole and healthy.”

A quick, second round of testing helped ensure we had incorporated all the feedback.

Is Khoon ka Rishta working?

The tool has been in use across eight districts in Bihar for over a year. A state-wide scale up has been planned by the government on the basis of an impact evaluation study we commissioned. It shows that:

Women exposed to the tool are more than twice as likely to report correct knowledge about IFA compliance.
They are twice as likely as those unexposed, to report correct practice.
Data suggests exposure to the tool leads to an increased demand for IFA tablets at the Village Health Sanitation and Nutrition Day meets.

Anecdotally, chemists are saying they have noticed an increase in sales of IFA tablets, because, even when women cannot get them free from the system, they are buying the tablets because they realise how fundamental they are to the health of their babies. We have used human-centred design to create tools for other products and services that are available at village health sanitation and nutrition days, such as contraceptives, oral rehydration salts for diarrhoea management and complete immunisation. These tools are non-digital yet innovative.

This proves something else as well: keeping the user front and centre, resetting the paradigm, checking ideas and assumptions and learning from failure are not very different from how communication gets done in the first instance. But if you want to walk the tightrope between disruption and delivering outcomes, this approach definitely helps you to be surefooted in creating innovative solutions to problems of every kind, whether you are in Silicon Valley, or Bihar.

Design thinking and health communication: learning from failure

2017-04-20T13:06:29+00:00

What do you do when your audience is difficult to reach, tough to keep engaged and doesn’t understand concepts you take for granted? Priyanka Dutt offers some words of advice from her team’s experience of running a health communication ‘laboratory’ in Bihar, northern India.

Anyone working in international development will attest that human-centred design (HCD) has been a ‘trending topic’ in recent years. Design thinking has been applied to a range of challenges, from supporting democratic transition in Libya to building an all-terrain wheelchair for under $200. Melinda Gates even hailed HCD as the innovation changing the most lives in the developing world.

But what exactly is design thinking? It involves bringing together multi-disciplinary teams – think creative writers working alongside ICT specialists – to address challenges through rapid prototyping and repeated testing. At the core of HCD is building empathy with the people you’re designing for with the overarching aim of producing something genuinely valuable to them.

Marrying these principles with our own core value of putting audiences at the heart of everything we do, we decided to set up a ‘laboratory’ in Bihar, in northern India, which aimed to improve child and maternal health through communication. We saw Bihar as a great site for HCD-style innovation because it offered us the scope to test and fine tune new ways of using communication to promote healthy behaviours for women and children alike.

Bihar is home to 29 million women of reproductive age, who give birth 3 million times every year. And although Bihar’s maternal mortality rate has declined in recent years to 93 per 100,000 live births, it is still well above the Sustainable Development Goals target of 70. As for the communication challenges, less than a fifth of these women watch TV and only 12% listen to the radio.

Yet the lab’s early creations achieved a great deal. Over 50,000 people have graduated from our Mobile Academy training course, which is delivered through mobile phone audio messages. The course teaches health workers how to communicate more effectively to persuade families to lead healthier lives.

We also produced a set of cards and audio messages delivered via mobile phone – called Mobile Kunji – for health workers to use during their visits with families. The evidence shows that families subsequently asked health workers more questions and were more likely to follow advice on preparing for birth, family planning and how to feed babies.

Rethinking strategy: learning from failure

High on our early successes, we set about developing Kilkari (a baby’s gurgle in Hindi). This programme sends weekly audio messages about pregnancy, child birth, and child care, directly to families’ mobile phones, from the second trimester of pregnancy until the child is one year old. The aim was that Kilkari would be listened to across Bihar, by the most vulnerable families, with the greatest need and least access to information and services.

Drawing on lessons from two similar services from around the world, Mobile Midwife and BabyCenter, in addition to our own prior experience in Bihar, we were confident Kilkari would be a success. Just to be certain, we ran some tests before rollout and found that we had failed in our vision – and spectacularly so. We weren’t getting through to our main audience, women, as we weren’t using the right channels and language.

In the end, we went back to the drawing board on Kilkari four times, simplifying and stripping down the content time and again, until we got it right. Through repeated prototype-test-redesign cycles, we made the vitally important discovery that our basic assumptions about our audiences were wrong. So we went back to basics and asked ourselves the following questions to push us to rethink our strategy:

1. Is the content relevant and easy to understand?

We discovered that our content confused the audiences we were targeting, who didn’t understand even simple Hindi words like health (swasthya). Men understood more than women – likely due to their greater literacy and mobility – but Kilkari’s female focus meant that this wasn’t particularly helpful.

Audiences also struggled with other concepts we take for granted. They mainly think of time in mornings, afternoons, evenings and nights, but we’d referred to hours and minutes in our programming, time references which simply don’t exist for them.

Finally, we also found that the speed and style of content used for Mobile Kunji and Mobile Academy was overwhelming for Kilkari’s audience. For example, dramatising content confused our listeners, who didn’t understand why there were so many people on the phone, all talking to them at once. We needed to have a single voice and a single take-away, simplified to the most basic information audiences needed.

2. Are we getting through to our target audience?

We primarily wanted to reach women, but discovered that it was mainly men who owned phones with the credit needed to receive messages from Kilkari, a paid subscription-based service.

In response, we used tactics to prompt men to share information with their wives. For example, calls were scheduled for the evening when men were more likely to be at home, increasing the chances that they’d pass on what they heard.

To drive up subscriptions, we also ran promotions targeting men, which presented the Kilkari subscriber as a smart and engaged role model father, who cares about the health and well-being of his family.

3. Can we do more to keep our target audience engaged?

We did a big marketing push for Kilkari, partnering with phone companies to promote the service at 20,000 shops. This went hand-in-hand with community outreach through songs, street theatre, films, quizzes and much else. As a result, we initially got a lot of subscribers, but the drop-out rate was high, suggesting that the service wasn’t relevant to those signing up.

Applying HCD principles, we redefined our audience and rapidly tested solutions to come up with a new and improved marketing strategy. We partnered with community health workers, who were already in contact with the families expecting babies we were trying to reach and so could help us promote Kilkari to its intended audience.

We incentivised health workers by offering them free mobile talk time for every subscription they secured, and gave them even more minutes if subscribers stuck with the service for more than two months.

In the end, our total number of subscriptions dropped slightly, but those who signed up did so for the long haul – our dropout rate fell to less than 10%.

From lab design to adapting for scale and sustainability

Ultimately, the lessons we learned from our mistakes paid off. Flash forward to January 2016, when the Indian health ministry began its national roll out of an adapted version of Kilkari. Kilkari is currently listened to by 1.6 million families in 11 states across India, every week. In a survey of Kilkari’s listeners, three out of four women said they frequently followed advice they’d heard on the service.

We’ll remember Kilkari as the project that taught us the most, not just about how to design for our audiences but also about the value of learning from failure. There’s also the long-lasting satisfaction that comes with finally getting it right.

If you want to find out more about how ��tv Media Action used media and communication at scale to improve maternal, newborn and child health, go to our digital platform, Global Health Stories.

Priyanka Dutt is Country Director of ��tv Media Action’s India office. Priyanka’s most recent publication is Rethinking communication for child and maternal health, which reflects on ��tv Media Action’s Shaping Demand and Practices initiative to improve family health in Bihar, northern India. She tweets as @priydee.