As low- and middle-income countries transition from paper to digital systems, family planning programs can benefit from unprecedented opportunities to improve services. Investments in digital health tools have expanded exponentially, but information on what works—and what does not— remains limited and scattered. As investments have increased, digital applications and data fragmentation have proliferated, but stakeholders are moving towards more coordinated efforts to scale digital health solutions, support countries’ digital health infrastructure, and share evidence-based learnings.
This Digital Health Compendium enables users to explore case studies across a range of digital health technologies used to enhance family planning programs mainly in sub-Saharan Africa, but also in other regions of the world. Digital health applications in family planning programs can be broadly classified as those affecting demand generation, service delivery, supply chain management, and the policy and enabling environment. In many low- and middle-income countries, digital health innovations were adopted earlier in other health sectors, including HIV/AIDS, maternal and child health, and noncommunicable disease prevention and response. As a result, much of the impact evidence is likewise restricted to those sectors. To advance greater adoption of digital technology in family planning programs, more data and information on the challenges, opportunities, scalability, and results are needed. This compendium aims to consolidate emerging information and data on applications of digital technology in family planning programs to inform adoption and scale-up of successful approaches.
All of the case studies were submitted by the implementing organizations and include a description of the digital health intervention, program context, and, if available, important findings and lessons learned through rigorous evaluations or program data. The compendium facilitates a quick search for case studies based on the target user for digital health intervention, building block for the digital health enabling environment, family planning program classification, and country location. The case studies give policy and program decisionmakers insights on real-world applications of digital health, promising practices, challenges, and other lessons that can be applied to current and future programs.
Providing health workers with mobile-based video instruction and reference materials
Service Delivery Consultant
Johns Hopkins Center for Communication Programs
The information below appeared in the original case study.
Johns Hopkins Bloomberg School of Public Health Center for Communication Programs
Bill and Melinda Gates Foundation
Systems Development Manager
Johns Hopkins Center for Communication Programs
Health Care Provider, Health System Manager
Services and Applications
This case study was originally published in the mHealth Compendium Volume 5, developed by the African Strategies for Health project, implemented by Management Sciences for Health with support from the U.S. Agency for International Development (USAID). Updates to the original case study, submitted by the implementing organization in March 2021, appear in the final section of this case study.
Nigeria has one of the highest population growth rates in the world. The United Nations projects that the current population estimates of roughly 160 million will increase to almost one billion by the end of the century. Despite the pressing need, Nigeria has had a stagnant contraceptive prevalence rate (percent of currently married women who use contraceptives) of only around 15 percent and a fertility rate of 5.5 births per woman for nearly 10 years.1 The Nigerian Urban Reproductive Health Initiative (NURHI) managed by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP) discovered that the service providers in the cities of Abuja, Ibadan, Ilorin, and Kaduna were restricting the use of many family planning methods based on internal biases and reasons that included the client’s age, parity (number of births), their marital status, and whether their spouse had granted consent.
NURHI staff found that provider bias is difficult to change, and often remains even after refresher training. Due to the midwives’ work schedule, the desire to use videos as the medium for information sharing, and the need to track progress, a mobile-based solution was proposed. As a result, NURHI launched the Interactive Distance Education Application (iDEA) system for midwives in order to provide a platform for providers to access relevant educational content and resources from Android-based smartphones or tablets.
iDEA is adapted from the Digital Campus open source application OppiaMobile. Educational content is integrated into the application to reinforce skills after training to increase a provider’s ability and willingness to deliver family planning methods that are appropriate and based on clients’ desires and medical eligibility. NURHI, in conjunction with a local production company, developed instructional videos with an entertainment-education approach. Each video scenario features examples to help providers recognize their biases and then address them by suggesting alternative approaches towards counseling. Each scenario has a pretest and a posttest to gauge learning.
iDEA is integrated with Moodle, a popular open-source learning management system, which provides users with the ability to create educational modules complete with videos, images, text, or audio in minutes. OppiaMobile automatically converts the modules for use with Android, which users can install from Google Play. With a one-time connection to the Internet, users can download the app, install the educational content, and register, and then can run the application and content offline. (See image in Evaluation and Results.)
In Nigeria, pretests determined midwives’ knowledge of counseling techniques prior to exposure to educational content. The average pretest score was 70 percent while the ensuing post-test showed an average improvement of about 5 percent. One likely explanation for the relatively minor improvement in scores was that the midwives already knew the material; what they did not recognize, until a video role play was provided, was their own tendency to display a negative bias towards their clients. Qualitative interviews demonstrated that the midwives recognized themselves in the “bad” example of client counseling and they then felt uncomfortable with their own behavior. Focus group discussions were held; some midwives expressed guilt at having prevented clients from making their own decisions.
The self-assessments were typical in that the videos reflected and helped them recognize some of their biases. This was confirmed during the pilot test and during follow-up focus group discussions several months after initial deployment.
Usage statistics are routinely collected by the application and are uploaded to the administration server whenever there is a connection. The graph below reflects the typical usage rates where, for example, over the course of one week, 59 different users accessed 242 pages in the family planning module, attempted 129 quizzes, and viewed 587 media sources. (See Figure 1 above.)
An evaluation is planned for early 2015 using a two-arm quasi-experimental design with client exit interviews to compare providers with and without phones. Interviews will be conducted with providers to document perceptions about iDEA and assess diffusion. The provider interviews will help supply an explanation of the findings of the client exit interviews.
The public health community is in the midst of exploring whether wide-scale deployment of mobile technology will improve frontline health worker and health system performance. There are several parts to this question, including: (1) technical feasibility; (2) usability; (3) acceptability among users; (4) improvement in health outcomes; and (5) sustainability. The deployment of iDEA has satisfactorily addressed the first three issues, while a planned evaluation in 2015 will begin to address the fourth. The design of the program will, with time, prove to be sustainable given the low cost and accessibility of the open source components of the application and learning management system that form the core of the technology. With a planned integration of the mPowering Initiative’s media sharing platform, these components could provide a complete architectural design of an end-to-end educational media distribution system that any national or regional initiative could adopt in the future. Further plans for an open collaboration in the refinement of the tools and the overall distribution system will further enhance functionality and reduce the cost of future deployments.
Phase 1 and phase 2 of the NURHI project, implemented from 2010 to 2020 in three Nigerian states (Kaduna, Lagos, and Oyo) were closed out in December 2020, but a sustainability platform continues through The Challenge Initiative (TCI), which is replicating NURHI’s proven-to-work models in 13 Nigerian states (Niger, Ogun, Rivers, Gombe, Nasarawa, Kano, Bauchi, Anambra, Delta, Taraba, Plateau, Abia, and Lagos).
The scope of the digital health intervention remains the same: to provide FP service providers an opportunity for self-learning and self-evaluation, by emphasizing the key FP knowledge and skills learned during their traditional training and supportive supervision. It also allows FP service providers to self-assess and make the necessary corrections based on appropriate lessons designed to address common challenges encountered in FP service delivery.
The geographic coverage has increased and further expanded through TCI.
The functionality has also been improved to ensure increased speed and user-friendliness. For example, the revised app has an improved user interface, an added chat system, and improved authentication, especially for user registration, password recovery, and login.
The old app, which launched in October 2013, had a section on job aids that was removed from the revised app as recommended by end users, FP service providers.
The revised app was developed from scratch as a standalone app that no longer leverages Oppiamobile and contains the following new components:
Original Case Study
1. Demographic Health Survey Nigeria. 2003 and 2013.
NURHI, My Family Planning Guide: A Post-Training Tool for Family Planning Service Providers, https://nurhi.org/en/wp-content/uploads/2021/03/My-Family-Planning-Guide-Final_For-NURHI-2-Website.pdf.