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mHealth Solutions for Family Planning Services

Arundhati Char (arundhatichar@yahoo.com) leads U-Respect Foundation, Mumbai.Minna Saavala (minna.saavala@vaestoliitto.fi) works at Väestöliitto, a non-governmental organisation in Helsinki, Finland.

There is limited experience in India of using mobile phones for sexual and reproductive health services, including family planning, in rural areas where service coverage is still insufficient and accurate information is lacking. Information and integral support can be provided by leveraging mobile health (mHealth) services, but issues of privacy and gender sensitivity are crucial for its success.

Technological advances in information and communication technology (ICT) have been accompanied by much enthusiasm over the opportunities created by mobile technologies in healthcare services. This has led to various innovations that arguably have improved public health and healthcare delivery in less developed societies and also in resource-poor settings (Akter et al 2010; Chigona et al 2013; Garai 2011; Källander et al 2013; Thomas 2012; Smith et al 2016). Telemedicine, emergency services, text messaging services, supervision and support services to the healthcare service staff, and data collection are among the functions that mobile telephony has brought in as new opportunities to develop services that would cater also to the underprivileged, rural, and less educated part of the population, and attempt to cover the “last mile.”

Reproductive health is among the fields in healthcare that are in the most urgent need for services that would help reach out to geographically, socially and culturally remote areas and the most underprivileged populations. mHealth offers a great promise to help cater to the needs of people with limited healthcare and family planning services and information in their everyday environment.

Here, we aim to assess whether and what kind of mHealth services would improve sexual and reproductive health, supported by health resources, including services and products, and, thus, lead to behavioural change.

Indian mHealth Scenario

In India, access to mobile phones by way of over a billion mobile phone users (TRAI 2016) is far greater than traditional desktops, laptops and broadband, thus making mHealth all the more relevant when compared to conventional eHealth. There are unlimited opportunities and strategies for using mobile phones in implementing mHealth for healthcare. With an urban teledensity of 154% and a rural teledensity of 51% (TRAI 2016), India should be poised to incorporate mHealth into the very fabric of our healthcare delivery system.

As per an estimate, there are at least 20 active mHealth pilot projects in India being carried out by some state governments and NGOs as part of mGovernance initiatives. A few sporadic projects have been carried out by others as well. They include use of mobile games to enhance HIV/AIDS awareness (10.3 million game sessions were downloaded in 15 months). Handheld devices were used to collect raw health data which were transmitted in real time to the health information system database. Disease and epidemic outbreaks have been tracked and daily health alerts have been sent to subscribers for nominal charges. (eHEALTH 2011)

 

However, “access to technology, end user and healthcare provider acceptance, lack of regulatory issues, logistics and availability of appropriate, need-based, customised solutions are some of the major challenges in the way of widespread utilisation of mHealth” (eHEALTH 2011).

The existing projects and applications in reproductive mHealth in India and beyond have mostly targeted the health of pregnant women and the newborn to help monitor and follow up on healthcare service use and health status of the clients, organising emergency services, and HIV-positive patients, as well as for disbursing information on prevention of HIV (Shet et al 2010; WHO 2011).

However, the use of mHealth in the area of family planning is thus far very limited. Some hotlines have been established in India, but these are run by for-profit organisations (WHO 2011). A recent initiative of the Government of Maharashtra was to open a toll-free helpline on sexual and reproductive health issues available to adolescents (Mascarenhas 2014), but the activity has fizzled out.

Here, we suggest that a serious attempt is needed to make use of mHealth in the field of family planning and sexual and reproductive health for the general population as well, other than pregnant women or the HIV-positive, to include all adolescents, women and men in need of contraception and information regarding sexual health.

Use of Basic Mobile Phones

We ground our views on a baseline survey carried out in two resource-poor areas in rural Maharashtra in 2015,1 on information from a non-governmental organisation (NGO)-based reproductive mHealth project,2 and on a literature review. The survey mapped mobile phone use, and family planning practices and knowledge. It was carried out in a sexual health intervention area and in another similarly profiled area with no specific intervention except for the government family planning programme.

Although smartphones are spreading fast—220 million smartphone users in India, 50 being sold every second (Hindu 2016)—our survey found that in the two surveyed areas in rural Maharashtra only a small proportion had access to a smartphone (14% and 15% in the two areas). The main issue is the expense: for the poorer segments of society, a smartphone is still far from affordable. For today’s needs, it is necessary to capitalise on basic mobile phones. While the cheapest smartphones in India cost anywhere between ₹2,500 and ₹3,000, the cheapest basic mobile phones cost barely ₹400. Clearly, affordability of smartphones is still a concern among the bottom of pyramid (BoP) population and, for some time now, using basic mobile phones for mHealth solutions will be more apt if one has to have an impact on this population.

Needs of Rural People

One of the most crucial issues in reproductive health in rural India is the lack of information concerning contraceptive methods and lack of support for use of reversible contraceptive methods. In the surveyed areas in rural Shahpur and Igatpuri in Maharashtra, where the majority of the population has a very low socioeconomic standard, every other married young male respondent and a third of married young female respondents were unaware of any contraceptive method.

Nearly a third of those who did not want to have any more children did not use any kind of contraception (termed as couples that had an unmet need for contraception). The baseline survey also revealed the prevalence of misleading rumours about modern contraceptives and sexual health. According to the health intervention by U-Respect Foundation, misconceptions about contraceptive methods and lack of support to those who adopt such methods (for example, helping to cope with possibly occurring side-effects) is a major cause for non-continuation of the use of reversible contraceptive methods.

It is remarkable that even in rural, less developed areas with poorly educated populations such as those surveyed, the respondents had a very welcoming attitude towards and were positively attuned to suggested reproductive health services provided via mobile phone. The majority of women and few men were personally inclined to contact such a service number for family planning. In fact, the NGO experience in Shahpur clearly showed men being enthusiastic about calling the helpline with queries and concerns regarding such issues, confirming that this can be a good strategy to encourage male participation in reproductive health and family planning programmes. Experiences from other studies, such as in the Democratic Republic of Congo, show that men used such services even more often than women did (Corker 2010).

Privacy and Gender

Gendered asymmetries have so far been taken into account poorly in planning mHealth coverage and services. In our survey areas, only 30% of women respondents had a phone available throughout the day, whereas 80% of men had access to a phone all the time. A third of women had it in their use in the evenings or at night. Most phones are in communal use, used by more than one person.

This means that issues related to sexual and reproductive health that are surrounded with a need for privacy cannot be communicated via text messages or voice mails, which can potentially be accessed by persons other than the recipient of the message. The service number should be made available where vulnerable and resource-poor clients, such as rural adolescents and women, can call at the time and from location most convenient for them. Issues of privacy and gender sensitivity are crucial for the success of mHealth services among the underprivileged segments of the population.

Text-based services do not work in remote rural areas because a considerable proportion of people are still illiterate or have poor ability to read any kind of script, not to mention the Latin script. In the surveyed areas in Maharashtra, 18% of married young women were illiterate as opposed to 11% of men. These are the people most requiring reproductive health service support and information. Reaching the poorly literate is much easier through voice-based services than through SMS or other textual forms of mHealth messaging. In another study in a rural area close to Bengaluru (DeSouza et al 2014), among those who preferred to receive medication reminders by phone, only one in 10 preferred to have these as text messages. Similar reports on the preference of voice services have come also from field projects (Betjeman et al 2013).

The common challenges reported in mHealth in developing societies are issues related to language (various scripts and languages, potential misinterpretation of written information, level of literacy), timing of messages, mobile network fluctuations and incomplete coverage of mobile networks, insufficient data privacy, and mobile phone turnover (Davey and Davey 2014; Garai 2011).

The issue of mobile network reach would need considerable commitment from governments to ensure each and every point in the rural and far-flung areas have mobile connectivity. Without such infrastructure, all the effort to use mHealth solutions would fail.

Conclusions

When targeting vulnerable subjects in resource-poor settings, voice-based call centres or helpline services in sexual and reproductive health are promising advancements (DeSouza et al 2014). Reading text messages is not easy for poorly literate subjects. Moreover, when the same phone is shared by several persons, it is difficult to maintain privacy and direct the message to the relevant person only. However, if a helpline is available, clients are able to make a call at a moment suitable to them.

When designing mHealth services, it is essential to listen to the client experience: what the people’s needs are, and what kind of services would correspond to their everyday predicaments (Gurman et al 2012; Motamarri et al 2012). Especially for the young and the women, the call centre helpline is very accessible as they are able to choose the time and place of call by themselves, and they can maintain anonymity. If they risk being identified, they would most probably not contact available services at all.

Smartphones are becoming more and more common in rural areas too. However, given the economic hardship among the underprivileged population in such areas, widespread smartphone coverage is still a long way in the future. As for the need of the hour, instead of focusing on apps for smartphones, the main interest should be directed to the establishing of non-profit call centres and service centres that are able to cater to people’s information and personal support needs in reproductive health issues. This could be done via mainstreaming public call centre services to a clearly targeted clientele or by outsourcing the service to NGOs or social enterprises.

India can rise to the track of social development not by forgetting the most underprivileged, but by providing them the bounty of technology in the form that is acceptable and accessible for their health-seeking. When adapting new technologies to old problems and challenges in preventive care and behavioural change in reproductive health, it is necessary to return to the old wisdom of privileging the clients’ felt needs.

Notes

1 The survey was carried out among married men and women aged 15–35 years, and unmarried adolescent boys and girls aged 15–19 years in Shahpur and Igatpuri. The total number of respondents in the two study areas was 300. The data is available with the authors on request.

We would like to thank Sangita Kulathinal for her expertise in analysing the data as well as developing our commentary, and Sulabha Shertate from Vachan in Nashik for her generous help in data collection.

2 “Project Vikalp: A Family Planning m-Health Initiative,” http://urespect.org/ourprojectdetails?Id=1104.

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Updated On : 16th Mar, 2018

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