The role of mobile in increasing nutritional behaviour change in Malawi
“In 2016 my wife was pregnant and I was following this service because I wanted to follow the right nutritional procedures so that my wife should give birth to a strong and healthy baby.” – Ramsy, Rural, Farmer, 27
Airtel Malawi, in exclusive partnership with HNI, provides a value-added service (VAS) branded as Airtel 321 to their network subscribers. The service includes topics on agriculture, nutrition, weather and gender-specific content which can be accessed via simple phone, a feature phone or a smartphone. The 321 service is available under similar agreements between MNOs and HNI local across sub-Saharan Africa, Asia and the Middle East. As part of the mNutrition initiative, the GSMA collaborated with HNI in Malawi and the research was the first to be completed from the mHealth component.
Scale and re-launch of the Airtel 321 service in Malawi
Airtel 321 launched nutrition, maternal and child health content back in September 2015. It received initial traction and acquired over 50,000 unique users in the first month it was launched. Despite this usage spike, the repeat usage on the service was low – through GSMA in-house analysis, we have found that some users were dialling in without accessing actual content, and many users were not returning to the service after an initial trial. The baseline phone surveys established that the need for such content was in fact very high as users had relatively low levels of knowledge about correct nutritional practices during pregnancy and the first 100 days of life, and their actual behavioural practices were poor.
Our user research manager conducted in depth field studies to identify the key areas around user engagement and communicating the messages in a way that drove behavioural change. The principles that were applied during the research can be found within the recently published toolkit, which shows how human-centred design can be used to derive the real needs of the end users.
Bringing all elements of the research together and through a joint product workshop with Airtel and HNI teams, we identified some key aspects of the product that needed improvement and made a series of improvements to the service:
We monitored the changes on the service to see whether they would affect user behaviour. Last March, we conducted the endline phone survey to evaluate whether these service improvements had helped increase knowledge and behavioural change. The results were extremely positive.
The messaging managed to drive a 17 per cent increase across the board in nutritional knowledge. The largest increase was in breastfeeding practice, with a 30 per cent increase from baseline (indicated in Figure – 2). This intervention has the greatest potential for impact on the health of a new-born child, with the potential to prevent 13 per cent of all deaths in under-fives in the developing world (Lancet 2013).
Furthermore, we have seen an increase in actual nutritional practices across the board, with an average increase of 22 per cent across all questions (as indicated in Figure – 3). The greatest increase in behavioural practice was again in breastfeeding, with a 35 per cent increase from baseline.
Here is the difference between knowledge and practice from the baseline of July 2016. There were significant gaps between knowledge and practice in the baseline (indicated in blue in Figure – 4) . By comparison, we can see by the endline, this gap has been significantly reduced (indicated in red in Figure – 4) and across most questions, the gap was cut to only a few percentage points if not eliminated altogether. This content and mobile as a platform has the capability to not only disseminate information but also actually reinforce the information and enable behavioural change.
One of the starkest differences between baseline and endline was the elimination of the gap between education levels. The difference in practice between those whose highest level of education being primary school and those who had gone on to further their education (indicated in blue in Figure – 5). By the endline, this gap had been significantly reduced (indicated in red in Figure – 5). This shows the power of the platform at reducing the gap between peoples with different levels of education. It would indicate that through this platform the content is reaching and affecting the behaviour of those at the bottom of the pyramid, particularly as most content was accessed through IVR (Interactive Voice Response) so illiterate users can access information.
The research highlights some incredible achievements to date in Malawi. An increase of 22 per cent in positive nutritional practices across the identified questions is a great result for the 321 service. With over a quarter of a million unique users receiving nutrition content to date and an upcoming national marketing campaign to help drive users, we can only see this service going from strength to strength, as it grows and increases impact within Malawi. At the heart of this change is mobile; it acts as a platform to disseminate information, reinforce positive information and level the playing field for those at the bottom of the pyramid.
Survey methodology: two phone surveys six months apart, with 800 participants for each. Second survey conducted three months after major changes were implemented. Complementary to this was a series of focus group discussions.
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