Using digital technologies to drive behavioral changes towards improved public health outcomes: The FamilyConnect Application in Uganda
The foundation for lifelong health is laid during the 1,000 days between the beginning of pregnancy and a baby's second birthday. During this time, our environmental surroundings, such as our eating patterns, stress levels, and adversity greatly influence how well our health develops in the future. However, many primary health facilities in Sub-Saharan Africa are underfunded, under-equipped, and understaffed, making it difficult to provide critical lifesaving mother and child health (MCH) services. Furthermore, insufficient, low-quality MCH care dissuades mothers from using any available MCH services, such as prenatal check-ups or birth in a health facility. Uganda is still struggling with delays in seeking key MCH care like antenatal care and delivery by qualified personnel. The country currently has a maternal mortality ratio of 189 maternal deaths per 100,000 live births, against the global recommendation of 70 maternal deaths per 100,000 live births. Research indicates most of maternal and child deaths are due to preventable causes like malaria, pneumonia, diarrhea, hemorrhage, eclampsia, unsafe abortions, and infections. A complete continuum of care is a key success factor to reducing health care gaps among women and children, yet it remains a big challenge in most countries in the sub-Saharan Africa region. For example, Uganda is still dealing with various poor practices across the continuum of care from pregnancy and childbirth to newborn care which require information sharing and sensitization at the community level in order to be overcome.
Over the past two decades, Africa has experienced an incredible boom in the use of mobile phones and other digital technologies. Many countries, including Uganda, have seized the opportunities these technologies offer to tackle the barriers that geography and scant resources pose to both access to and provision of services and at a relatively low cost. Thus, FamilyConnect (FC) was adopted in Uganda as a viable digital health intervention to support behavioral changes needed for the delivery of safe, accessible, coordinated, and effective maternal health care services. FamilyConnect in Uganda was launched in partnership with the Ugandan Ministry of Health and UNICEF and leverages mobile technology to provide essential health information to pregnant women, new mothers, and caregivers. As of 2020, the system was in use in 32 districts in Uganda with 20,000 community health workers (CHWs) and 88,000 women enrolled. By 2022, the system had been scaled up to 42 districts.
A recent study was undertaken to assess the contribution of FC towards improvements in the delivery of MCH services like attendance rates for antenatal care and facility-based deliveries. The study was done by Compelling Works Uganda, in collaboration with the Ministry of Health, and sponsored by the Right Foundation.
The study incorporated feedback from mothers, community health workers, and district health team members (DHTs) through a survey questionnaire, focus group discussions (FGDs) and Key informant interviews (KIIs). Through these means, barriers and enablers to usage of the application plus recommendations for future scaleup were identified. The study also identified the benefits that the application brought to mothers and health workers. The study sample included 9 districts that had used FC with representation of all regions of the country.
The study found that the total ANC visits increased substantially from an average increment of 1.5% per year in the pre-intervention period (2017-2019) to 5.5% per year after the intervention (2020-2022). The findings indicated a strong association between exposure to the FC intervention and the utility of ANC services, demonstrating that FC effectively increased the utilization of ANC services which was a key goal in establishing the application.
The FC application complemented other interventions geared towards improving MCH outcomes by enabling easy sharing of targeted health information including reminders to attend ANC, nutrition, immunization and Information about HIV. The FC application leveraged technology and data to ensure mothers and children receive timely and necessary information to propel them to seek healthcare.
The application was especially found to be useful in rural and/or hard-to-reach areas since the use did not require the physical presence of a health worker and messages could be received on a simple phone through the SMS platform. Study participants alsonoted that the messages were received in their local languages that made them easy to understand and follow.
The application was rolled out through the Village Health Teams (VHTs)/ Community Health Workers who were trained on the use of the application especially in supporting mothers to enroll on the system. The VHTs are also trained to deliver health educationand provide support to mothers at the local level. These CHWs act as a bridge between families and formal health services, identify high-risk pregnancies and refer mothers to facilities, as well as educate families on child nutrition, hygiene, and preventive care. The study found that this grassroots involvement of VHTs made the adoption of the application easier and gave the mothers more confidence in accepting the tool and the information shared.
Lack of mobile phone ownership among women and network connectivity challenges were cited as major barriers to the efficient use of the FC application. Another hurdle highlighted was domestic violence, which some mothers faced as a result of their husbands' illiteracy, mistaking FC messages for those from men outside the relationship.
Some of the key recommendations from the study included system upgrades to include messages for mothers who have lost children (some still needed psychological support and postnatal care); expanding the number of languages in the application to cover more of the country's major ethnic groups; focusing effort to increasing male participation in the program in order to increase uptake and mitigate the negative effects of domestic violence.
FamilyConnect’s approach to using information in promoting and improving maternal and child health outcomes in Uganda demonstrates the power of information technology-driven and community-centeredinterventions. Throughreal-timeinformationsharing, grassrootsinvolvement, and continuous evaluation, FamilyConnect is setting a model for how technology and community collaboration can lead to healthier families and communities in low-resource settings.
Simon Ndira1, Angelica Kiwummulo1, Francis Xavier Wasswa1, John O. Mogaka1, Benjamin Ailak1, Chris Ebong2, Divine Mercy Kemigisa2
Compelling Works Limited
Ministry of Health Uganda Department of Maternal and Child Health Services.
