MANTRA: a serious game improving knowledge of maternal and neonatal health and geohazards in Nepal

Abstract

Description of problem: Dhaka urban slum dwelling female adolescents are difficult to reach adequately with health messages through traditional home visit by community health workers for counseling, because many of these adolescents in Dhaka urban slums have a job outside home. We designed and implemented an innovative health communication intervention ''Health Boost''-an approach to provide reproductive, maternal and newborn health information for married female adolescents using the voice message system on mobile phone. Methods: We delivered 'Health Boost' (HB) voice messages to enrolled married adolescent girls, twice a week, with re-listening option. Pregnant and non-pregnant participants received separate sets of messages. Enrollment was started after baseline survey (September 2016) and continued during October 2016-April 2017. Pregnant participants received messages at least for 6 months before delivery. For evaluation, we followed pre-post observation study design and had the endline survey in November 2017. Results: Comparing HB non-receivers at baseline (n = 321) and HB receivers at endline (n = 45), statistically significant improvement was revealed for knowledge on danger signs-(a) during pregnancy (55.5% vs. 93.3%; p < 0.001), (b) during child delivery (54.2% vs. 82.2%; p < 0.001), (c) for newborn (56.7% vs. 75.6%; p < 0.02). We also found significantly higher utilization of service among HB receivers: Utilization of antenatal care increased from 70.4% to 87.5% (p < 0.02); and use of postnatal care increased from 31.6% to 73.7% (p < 0.03). Lessons: 'Health Boost' messages were instrumental and effective to increase knowledge and service utilization among married adolescent girls in Dhaka urban slum areas. Key messages: Voice message is an innovative way to reach hard-to-reach population by using mobile phone technology. Voice messages were instrumental and effective to increase knowledge and service utilization among urban female adolescent population, for reproductive, maternal and newborn health. Background: Mobile technology is increasingly important for delivering public health interventions to remote populations. This research study developed, piloted, and assessed a serious game for mobile devices that teaches geohazard, maternal, and neonatal health messages. This unique mHealth intervention aimed at low-literacy audiences in low resource settings is part of the Maternal and Neonatal Technologies in Rural Areas (MANTRA) project: Increasing maternal and child health resilience before, during, and after disasters using mobile technology in Nepal. Specifically, we assess impact of the serious game to improve knowledge gain in our target audience. Methods: Co-creation with the MANTRA team and local stakeholders in Nepal identified core needs, developed appropriate pictograms and mechanics, and tailored the pilot game to the local cultural context. Through picture matching with immediate audio and visual feedback, the game teaches 28 learning objectives in three modules: maternal health, neonatal health, and geoha-zards. To assess the game, 35 participants were recruited in Kathmandu and villages in Kavre district. Sessions consisted of pre-test assessment, playing the game, post-test assessment, and a focus group to elicit qualitative feedback. Results: The knowledge assessment quantified knowledge gain. Overall, the group averaged a normalized 6.8 point improvement (p = 0.000022). Change in the geohazard module was 9.5 points (p = 0.001), followed by maternal health (7.4 points, p = 0.007), and neonatal health (4.3 points, p = 0.83). Four learning objectives had statistically significant change (p < 0.05). Feedback demonstrated high engagement, motivation , and usability of the game. Conclusions: This MANTRA study is a unique mhealth intervention of a serious game to teach core health and hazards messages to low-literacy audiences in rural Nepal. The pilot intervention demonstrated statistically significant knowledge improvement among participants. Key messages: The pilot MANTRA mobile serious game intervention is a novel idea, to bring public health knowledge to difficult to reach vulnerable populations, including often ignored illiterate audiences. The pilot MANTRA mobile serious game intervention demonstrated a statistically significant knowledge improvement of geohazard, maternal, and neonatal health learning objectives among participants.