The train slowly creaked to a halt in the bustling Lucknow train station, the capital of Uttar Pradesh in the northern Gangetic plains of India. I was guided into an SUV where we set off on our final leg, a 4-hour drive to reach Shrawasti district. Passing paddy fields and a necessary chai stop in a dusty roadside restaurant, I finally arrived ‘in the field’.
I was greeted by Usha who excitedly ushered me towards her as she sat outside her home in Katar. She burrows her hand deep into her backpack and removes an android tablet device. “I would never want to go back to paper-based job aids,” she enthusiastically tells me.
Usha is preparing for her monthly mother-to-mother-support group meeting. She has begun using the mobile health (mHealth) tool at these meetings not only to collect community-level household data on diarrhoea, but to provide health education to pregnant and post-partum women within her work catchment area, specifically on themes surrounding health and water, sanitation & hygiene (WASH).
Its 1pm, women slowly begin to arrive at the meeting house. They cluster in a seated circle. The humidity and heat are stifling, despite a faded old sari hung as an awning to protect the group from the midday sun. A gaggle of children follow behind their mothers and are collectively silenced with a resounding ‘Shhhhhhh’. Babies are gently helped onto a breast. And so Usha is able to begin teaching her health education module. Today it’s on oral rehydration solution and zinc treatment for diarrhoea in children under five.
Usha is a community health volunteer. She’s been working as part of Save the Children’s Stop Diarrhoea Initiative since its inception in 2015.
In India, over 1 million children under the age of five die every year. Approximately 10% of the annual under-five deaths (117,000) – 320 child deaths every day – are attributed to diarrhoeal diseases. 80% of these deaths are of children under two. Therefore, community health volunteers like Usha, disseminating targeted health messaging to parents and care-givers of newborn babies and infants, have the potential to significantly improve hygiene behaviour within communities – and to drive up improvement in health outcomes.
In 2009, the World Health Organization and UNICEF released global guidance for countries to implement a package of health, water, sanitation and hygiene interventions to control and prevent diarrhoea, echoing knowledge about effective programming for child survival. The report Diarrhoea: Why children are dying and what can be done has become known as the 7- point plan for diarrhoea control based on its recommendation for scale-up of seven evidence-based prevention and treatment interventions.
The 7-point plan for the prevention and management of childhood diarrhoea is the precursor to the World Health Organization’s Global Action Plan for Pneumonia and Diarrhoea. This is currently the leading strategy for child survival. The interventions are basic community-based interventions, low cost, and easy to establish and monitor. Yet countries with the highest burden of infectious disease in children under five do not achieve this coverage. Usha begins to use the digital modules on diarrhoea prevention and control, developed by Save the Children India, with the help of a Bluetooth speaker to enable adequate audio for the group to all hear. She pauses intermittently to ask the group to recite key messages, in order to make sure they have understood.
“The online modules command greater attention from the mothers in the group. I’ve noticed increased participation since I integrated it into my work as people are interested to see and hear it. There’s something about a visual screen that holds people’s attention more than when I just used to use my paper-based job aide on its own.” Usha
The Stop Diarrhoea Initiative sought to understand the challenges involved in implementing all the seven points of the plan through existing systems in countries with the highest burden of diarrhoea, including India. The programme is being implemented between 2015 and 2019 reaching 2 million people in India and is supporting service delivery, management support, research and advocacy, covering WASH and health interventions. In particular, mHealth has been used as a platform to support some of the programme’s communication activities to promote social and behaviour change.
mHealth is still an emerging concept, but with a rapid rise of technologies and improved accessibility, mHealth has gained support in the last 10 years as a way to accesshard-to-reach communities. It offers new and creative opportunities to improve health outcomes, while providing remote support and supervision. With the development of visual health education models and digitised community health information management, community health volunteers like Usha can also be supported remotely.
It’s difficult to weigh up mHealth interventions and tools against other priority, traditional evidence-based interventions. Most health systems are severely overburdened, which means they are constantly challenged by the need to make difficult decisions about competing priorities. Since mHealth lacks a strong evidence base to verify its impact on health outcomes and health systems, the experience of the Stop Diarrhoea Initiative is paramount to contribute to this growing body of evidence within the mHealth global community. The community health information management software, called BRISK (Bal Raksha Information System for Knowledge), developed by Save the Children India, seeks to enable more robust surveillance, tracking and follow-up for children under five with diarrhoea to ensure timely referrals are made and treatment completed.
“I take the tablet on house to house visits within my village. I check if there are any children within the household who have diarrhoea. If they have, I then collect information to input into the mobile application, which helps me decide if the child needs a referral to a health facility – depending on the severity. If the child is referred, the app then reminds me to follow up within three to five days to check the child went to the facility to get treatment, and how long it took them to recover.” Roshini
Community health volunteers like Usha are ideally suited for collecting community level data using an mHealth tool. Typically, they reside among the communities they support, are well respected and provide an array of outreach and health counselling to communities and hard-to-reach populations. It’s well documented that the role of community service providers has had a positive impact in communities, particularly maternal, newborn and child health. mHealth tools such as the interventions used in the Stop Diarrhoea Initiative capitalise on the role of the community service providers and recognise that this can leverage communities to become active participants and agents of change within the healthcare system.