Mobile mental health channel

While almost all women develop mental disorders during pregnancy and after birth with evidence striking connections between maternal mental illness and poor birth outcomes, integration of mental health communication and support in existing care in Uganda is limited.   The proposed mobile enabled mental health channel is a phone based last-mile application that effectively delivers mental and MNCH communication and timely connects women to the health system. It offers holistic in-app based modules with in-built progress tracking tools; mental health analyzer, Pregnancy tracker, ANC calculator, High risk notifier, Postnatal & Newborn progress tracker. These are integrated with audio-visual instructions which serve as reminder-call alerts auto-shared by CHWs with women during visits and auto reported to the health facility. Scaling up this solution will foster knowledge of women & effective delivery of mental health information, amplify access to life saving services such as ANC, skilled deliveries and consequently reduced mortality. 

Globally, about 10% of women experience a mental disorder during pregnancy and 13% after birth with developing countries like Uganda having higher rates, 15.6% and 19.8% respectively. Evidence associates maternal mental illness with poor pregnancy outcomes as the condition triggers interrupted health seeking practices. Consequently, this exacerbates maternal-neonatal mortality, low-birth weight, diminished emotional involvement, neglect and hostility towards the newborn. Buyende district is characterized by poor RMNCH indicators; teenage pregnancy at 30.5%, 12% of 10–19-year girls are married, 1 in 4 girls 15-19 have begun childbearing, 12% of girls reported to have been forced into unwanted pregnancy. These coupled with extreme poverty prompt extreme stress that escalates incidences of mental illness. Whereas CHWs are earmarked for delivery of community level mental & MNCH health education and care, they have varying levels of education and competence hence pass-on non-effective information. As a result, this reinforce knowledge gaps across women and girls on adoption of protective behaviors facilitating adherence to myths and negative cultural attitudes. Therefore, equipping CHWs with mobile enabled mental health toolkits with reloaded content and auto connected to the health facility will go a long way in ensuring effectively delivery of mental & MNCH information.

The proposed mobile enabled mental health channel, a mobile-phone based last-mile integrated health application effectively delivers mental health and MNCH communication and timely connects women to the health system. It offers holistic in-app based modules referred to as ‘Channels’ with built-in progress tracking tools; Mental health analyzer, Pregnancy tracker, ANC calculator, High risk notifier, Postnatal & Newborn progress tracker. Trackers are integrated with audio-visual instructions which serve as reminder-call alerts shared by CHWs with women during visits and auto reported to the health workers. The channel uses an innovative digital audio-visual supported localized content in multiple languages suitable for semi-literate and illiterate women helping in quicker understanding and longer retention of information for behavior change. These in-built CHWs toolkit is auto-linked to the health worker toolkit. This enables health workers to track the activities of each CHW, monitor progress of the mental condition/pregnancy, initiate timely service delivery and referral, sound alert for follow up support and reminders for missed appointments including resolving reported high risk pregnancy queries. The Channel also has a multi-tier ‘Real-time Activity’ dashboard for all hierarchical levels of the health system interoperable with HMIS / DHIS2 and allows live monitoring by stakeholders. 

Women of reproductive age: Engaged in inception workshops to ascertain area specific prevailing information needs and preferred language. These receive weekly follow visits involving voicing of mental-maternal health care support throughout pregnancy and after birth. Apparently, the solution is supporting 3450 pregnant women in Jinja district, with the solve grant WHCUG & ANDIC will scale to 4000 pregnant women in Buyende district, Uganda

CHWs: Benefit from skills training in running of the Mobile mental health channel, are supported with mobile devices, facilitated to conduct weekly mobile enabled counselling, auto tracking of beneficiaries, auto reporting and auto referrals of women to the health facilities  

Health workers: Involved in content development, benefit from skills training on the application & quality handling of clients and supported with mobile connected devices. Using the toolkit, a midwife tracks activity of each CHW, monitors progress of each woman, sounds alerts for follow up and reminders for missed appointments, resolves high risk pregnancy/mental-health emergencies and initiates timely service delivery

Project stakeholders: Ministry of Health & and District Health Teams are involved in review and approval of content, the channel further provides them with a multi-tier ‘Real-time Activity’ dashboard integrated with HMIS & DHIS2  for which real-time monitoring

CHWs are provided with tools to be able to carry out mandatory mental and emotion assessment every time they visit the household, and further supported on the actions, counselling and support they can offer during pregnancy and childbirth period. This will go a long way to ensure that the 20% of women in this time period are not neglected and therefore get the timely appropriate care they deserve. This will be facilitated by a mobile phone/e-health enabled technology, hence contributing to the reduction of mental health cases within the pregnancy and childbirth period. 

The proposed mobile mental health channel is a system changing strategy with a fully-technology linked model for development to help in reduction of adverse effects of mental health illness in pregnancy and consequently reduce maternal, new born & infant mortalities. It provides health communication and information through mobile phones suitable for rural & hard to reach catchments riding on the penetration rates of mobile phones. It uses iconic and innovative digital audio-visual supported localized content in multiple languages suitable for semi-literate and illiterate women for quicker understanding and longer retention of information. It offers holistic in-app based modules with built-in progress tracking tools such as; Mental health analyzer, Pregnancy week-by-week tracker, ANC calculator which help CHWs and the women to remain updated with progress of each pregnancy & mental risk state. These trackers are integrated with audio-visual instructions serving as reminder-call alerts by CHWs with women during weekly visits and auto reporting to health workers for immediate address. The CHWs toolkit is linked with the health worker toolkit which speak to each other, as such, the midwife can track activities & interactions of each VHT with the women under her, monitor the progress of the mental condition and or the pregnancy, initiate timely service delivery, sound alert for follow up support and reminders for missed appointments & resolve high risk pregnancy queries auto reported by VHTs. The application has a multi-tier ‘Real-time Activity’ dashboard integrated with HMIS & DHIS2  which makes real-time monitoring possible

On the client side, the single window integrated maternal-mental health channel runs on both android and windows operating systems with ability to work offline and synchronize with a remote server when mobile connectivity is available. Video and audio content integrated in the application is based on 3GPP / MPEG-4/MP3 formats with illustrative graphics in JPEG. The back end consists of a web-based platform integrated with enabling analytical and data visualization tools allowing export of data in standardized formats. The back end architecture is built on standards for Open Health Information Exchange ( OpenHIE) allowing interoperability with external platforms such as DHIS2

The proposed Channel is tested to build a new pathway for health education & communication through provisioning of authentic information to teenage mothers in rural catchments in convincing and exciting ways helping in quicker understanding and longer retention of information for behavior change and consequently trigger demand for health care seeking. To demonstrate that, under the on-going ending preventable Maternal and Newborn deaths, improve health of adolescents through Integrated Mobile Channels for providing healthcare information and services project  reaching 3451 pregnant women, The Channel,  has caused increase in uptake of lifesaving services ANC 4th visit increased from 47% at baseline to 84% midway, facility deliveries increased from 61% to 93%, maternal mortality in the cohort reduced from 5 to zero, neonatal mortality reduced from 54/1000 live birth to 5/1000 live-births .  Two,  the channel stocks and runs approved content of MOH which CHWs only  plays during community counselling visits, this wipes way the possibility of passing on varying information on yet similar subjects as illustrated in James, a CHW working on the project’ testimony “ With this mobile enabled communication tool kit, I feel equipped and for that reason, I now dive into the field with boldness to meet pregnant women because all I need to do is merely click & the phone does the talking”. Three, the in-built CHWs-health worker linked toolkit is modelled to enable health workers to take timely action to save lives. While the hierarchical multi-tier ‘Real-time Activity’ dashboard interoperable with HMIS / DHIS2 allows for live monitoring by stakeholders which enhance access to critical information and data for decision making and for effective, efficient program management

The solution as served the Population as follow:

a.         3451 pregnant women reached & connected with the Health system

b.         2391 new-born children enrolled for routine immunization & tracked throughout

c.         4012 adolescent girls reached with information on menstrual hygiene

d.         Capacity of 50 VHTs built using digital Maternal, Child & Adolescent Health tools.

e.         25 midwives/ nurses trained & 5 supported with connected mobile devices

The overall goal of the project is to ensure all women in pregnancy and childbirth have access to and utilize timely mental and emotional support in Buyende district of Uganda by 2025.

 Specific objectives:

a.         Initiate and increase active case finding for mental health during pregnancy and childbirth by  800 women in one year and 4000 women by the 5th year.

b.         Offer community based mental and emotional support during pregnancy and childbirth to 800 women on one year and   4000 in 5 years at the household level

c.         Earlier identification of mental health issues in pregnancy and childbirth and ensuring 85% of these can be managed in early stages at the household level by the CHWs.

d.         Ensure a 95% cure rate, 5% non-respondent rate, 80% referral successfully reached and managed

e.        Use evidence to bring e-mental health to national agenda through advocacy 

Financial: Lack of sufficient funds to expand the MIRA innovation to other geographical locations and inclusion of mental health modules on the MNCH-A program.

Technical:  Expansion requires additional staff with the experience in mental health, health systems strengthening, back end IT. These needs to be paid salaries to support the daily work.

Cultural: The local mentality that its normal for a woman in the pregnancy and childbirth period to have mental health issues. Secondly the fact that mental and emotional health care support has not been prioritised in the maternal and newborn care track for Uganda. These are key challenges in ensuring uptake of this particular innovation in Buyende.

Financial: Continuous advocacy for the solution to potential donors. Be on the lookout for any call for proposal. Application to different funding mechanisms, popularising the innovation to attract funding. This includes documentation of best practices and sharing these widely to attract funding.

Technical: This can only be sorted if there is financial muscle. However currently the roles are shared by the few staff available.

Cultural:  advocacy and continuous communications and community engagement with duty bearers to appreciate the effects of a poor mental state of the mother on the child. Proper documentation to generate evidence that is shared widely to break barriers to mental health care and programming. This includes policy formulation.

Name

Role

Nature of work

Franco Gabala

Chief executive officer

Full time

Daniel Irongo

Digital health M&E specialist

Part time

Namususwa Lorna Mary

MNCH specialist

Part time

Mental health officer

Full time

IT officer

Full time

This solution is implemented in a partnership between Women Health Channel and Alive NutriDietetic Clinic bringing together competencies in mobile health programming and maternal newborn and child health respectively. The team is technically competent and presents skills mix and experience in project management, monitoring and evaluation, maternal newborn and child health programming especially for rural setting and community health programming. We are members of the technical working groups for e-health and MCH both at national and subnational level. The team understands our health systems dynamics especially in the Eastern part of Uganda, is registered to operate in the region and has good working relationships with the district local government.

We are currently partnering with Alive NutriDietetic Clinic that offers technical expertise in Reproductive Maternal Newborn Child and Mental Health. They work on technical content that is input into into the application. 

The MoH and District health team approve the application, participate in our learning and support supervision. 

Health facilities offer services, supervise and coach community health workers

The community health workers follow up households, do counseling and conduct timely referrals to health facilities.

Our overall goal is to enable women improve maternal & mental health outcomes, self-manage their life and reach towards a larger goal of women empowerment. Our channel provides healthcare information through the widely established and available mobile phone platform even in the hard to reach catchments in a mode that builds on community and beneficiaries knowledge hence triggering empowerment, informed decision making and adoption of safe mental health and maternal care practices at household and at community level as the application uses iconic messaging system throughout the channel which enables women with low or no literacy levels understand issues easily and quickly. The channel also allows multiple registrations on one mobile handset taking in consideration that not every rural woman or CHW has a mobile phone and the phone can be shared in groups of women.  CHWs & Nurses/Midwives with window or android powered mobile devices, we just upload the channel and g train them on how to run the channel and the other hand, CHWs or midwives without window or android powered devices, the project supports them with connected mobile devices. Centrally, our project and or the application utilizes the existing health care delivery infrastructure to deliver integrated mental-maternal health information and services; already government deployed CHWs, nurses and midwives thus enabling wider stakeholder involvement for ownership but also lowing the cost of implementation for guaranteed continuity and sustainability 

The project design and implementation have and will involve key stakeholders like MoH, district health office, the sub-county authorities, health facility, community health workers and households. The project will work through established structures like health facilities and community health workers building their capacity to offer quality maternal and newborn services with specific focus on mental health illness. The project is designed with the end user in mind and therefore we have carefully made better choices of the activities that speak to the real community issues which are carefully integrated into routine structural activities for continuity.

The project will also convene learning and accountability meetings with stakeholders to share learnings leading to eventual integration of project activities into partners implementation strategies. Evidence will also be shared with MoH through the e-health and MCH technical working groups to guide planning and resource allocation as well as uptake of key innovations. We also intend to interest private health facilities for this innovation as a way of raising more revenue to sustain our programme but also contribute to scaleup.

The project aligns very well with Women Health Channel Uganda and Alive NutriDietetic Clinic 5-year strategic plans and therefore intends to utilize this project as a steppingstone for attracting more resources to continue with the project implementation of project activities. We shall diversify funding sources and develop long term partnerships with donors while exploring new opportunities using this experience