Can health information through mobile phones close the divide in health behaviours among the marginalised? An equity analysis of Kilkari in Madhya Pradesh, India

Abstract

Kilkari is one of the largest maternal mobile messaging programmes in the world. It makes weekly prerecorded calls to new and expectant mothers and their families from the fourth month of pregnancy until 1-year post partum. The programme delivers reproductive, maternal, neonatal and child health information directly to subscribers’ phones. However, little is known about the reach of Kilkari among different subgroups in the population, or the differentiated benefits of the programme among these subgroups. In this analysis, we assess differentials in eligibility, enrolment, reach, exposure and impact across well-known proxies of socioeconomic position—that is, education, caste and wealth. Data are drawn from a randomised controlled trial (RCT) in Madhya Pradesh, India, including call data records from Kilkari subscribers in the RCT intervention arm, and the National Family Health Survey-4, 2015. The analysis identifies that disparities in household phone ownership and women’s access to phones create inequities in the population eligible to receive Kilkari, and that among enrolled Kilkari subscribers, marginalised caste groups and those without education are under-represented. An analysis of who is left behind by such interventions and how to reach those groups through alternative communication channels and platforms should be undertaken at the intervention design phase to set reasonable expectations of impact. Results suggest that exposure to Kilkari has improved levels of some health behaviours across marginalised groups but has not completely closed pre-existing gaps in indicators such as wealth and education.

Which communication technology is effective for promoting reproductive health? Television, radio, and mobile phones in sub-Saharan Africa

“…Higher incomes and greater wealth have historically been associated with better health outcomes [ 59 ]. However, recent evidence has shown how mobile phone-enabled health communication has been successful in reducing health behaviour gaps for marginalised groups [ 60 ]. Findings support this evidence by showing that the positive potential influence of mobile phone ownership for the poorest is statistically significant and may help closing the gap with better-off women.…”

The impact of a direct to beneficiary mobile communication program on reproductive and child health outcomes: a randomised controlled trial in India

“…Similar patterns were observed for those without education and with two or more children. Efforts to assess the timing of calls per day are reported elsewhere 22 and broadly suggest that call answer rates were lowest earlier in the day and overall for those in the most marginalised sociodemographic groups.…”

“…Elsewhere we continue to explore equity considerations in greater depth. 22 Analyses of call data records made possible by MOHFW and with the support of technical partners including BBC Media Action, Beehyv and IMI Mobile were integral to our efforts to determine exposure to specific subsets of Kilkari messages by outcome and explore linkages between dosage of listening and reported health outcomes. Ours is the first evaluation of a mHealth messaging programme to make this link.…”

“…Similar patterns were observed for those without education and with two or more children. Efforts to assess the timing of calls per day are reported elsewhere 22 and broadly suggest that call answer rates were lowest earlier in the day and overall for those in the most marginalised sociodemographic groups. Primary outcome: exclusive breast feeding Kilkari was not observed to have a significant impact on exclusive breast feeding (ITT, RR: 1.04, 95% CI 0.88 to 1.23, p=0.64; IV, RR: 1.10, 95% CI 0.67 to 1.81, p=0.71).…”

Association between exposure to social media and knowledge of sexual and reproductive health among adolescent girls: evidence from the UDAYA survey in Bihar and Uttar Pradesh, India

“…Regarding education, less-educated adolescent girls are likely to have lower self-efficacy and less agency/autonomy to participate in household decision-making, potentially resulting in reduced access to digital connectivity. Evidence from rural Madhya Pradesh, India, showed higher digital technology engagement and responsiveness to digital health interventions among beneficiaries (pregnant and postpartum women of reproductive age 15–49 years) who were comparatively more educated [ 31 , 32 ]. Higher education opens doors to economic opportunities.…”