Feasibility and Acceptability of an Adapted Mobile Phone Message Program and Changes in Maternal and Newborn Health Knowledge in Four Provinces of Afghanistan: Single-Group Pre-Post Assessment Study (Preprint)

Abstract

BACKGROUND Mobile phone applications for health promotion have expanded in many low- and middle-income countries. Afghanistan, with high maternal and newborn morbidity and mortality rates, fragile health infrastructure, and high levels of mobile phone ownership, is an ideal setting to examine utility of such programs. We adapted the Mobile Alliance for Maternal Action (MAMA) messages, designed to promote healthy behaviors during pregnancy and the newborn’s first year of life, to the Afghan context, piloted, and assessed the program in Kabul, Herat, Kandahar, and Balkh provinces. OBJECTIVE To assess MAMA pilot program feasibility and acceptability, and to examine change in reported maternal, newborn, and child health (MNCH) knowledge and attitudes among participants from baseline to follow-up. METHODS We conducted a single group study with data collected within ten weeks of enrollment, repeated approximately six months later. Data were collected through face-to-face interviews using structured questionnaires. Eligible participants included pregnant women who had registered to receive fully automated mHealth messages and their husbands. Assessment questionnaires queried sociodemographic details; knowledge, attitudes and health care seeking practices; and at follow-up, intervention experience and acceptability. The number of messages received by a phone number was extracted from the program database. We descriptively analyzed feasibility and acceptability data and compared MNCH knowledge change between baseline and follow-up measures using the McNemar chi-square test. RESULTS Overall, 895 women enrolled in the MAMA program. Data from 453 women (72.5% of pretest) who received voice (n=302) or text (n=151) messages, and 276 men (64.6% of pretest) who received voice (n=185) or text (n=91) messages contributing data at both time points, were analyzed. At follow-up, 699 participants (96%) were still enrolled in the MAMA program; voice message and SMS subscribers had received 43 and 69 messages on average over the 6-month period, respectively. Participants who were voice message subscribers and female participants more commonly reported missing messages compared with text message subscribers and men; predominant reasons for missed messages were subscribers being busy with chores or not having a shared phone. Over 90% of men and women reported experiencing benefits from the program, mainly increased knowledge, and 226 female subscribers (50%) reported referring someone else to the program. Most participants (377 women, or 83%, and 258 men, or 93%) reported they believed it was beneficial to include husbands. Results indicated that joint decision-making regarding maternal and child health care increased overall. Proportions of participants with correct knowledge significantly increased for all but one MNCH measure at follow-up (P<0.05). CONCLUSIONS This assessment indicates the pilot MAMA program is feasible and acceptable in the Afghan context. Research should be conducted to determine whether program participation leads to improved MNCH knowledge, health practices, and health service utilization in this fragile setting prior to larger scale-up. CLINICALTRIAL