A mobile health app may improve maternal and child health knowledge and practices among rural women with limited education in Uganda: a pilot randomized controlled trial

Objective: This article describes the impact of a mobile health app (MatHealth App) on maternal and child health knowledge and practices among women with limited education. Materials and methods: Pregnant women initiating antenatal care (ANC) were randomized (1:1) to the MatHealth App versus routine care. Participants were followed until 6 weeks after delivery. Questionnaires for assessing knowledge and practices were administered to participants from both arms at baseline and endline. Using logistic regression, we estimated the difference in odds of having maternal health knowledge. We reviewed clinic records to capture maternal health practices. Results: Of the 80 enrolled participants, 69 (86%) completed the study with a median follow-up of 6 months. Women in the MatHealth arm had 8.2 (P =. 19), 3.6 (P =. 14), and 6.4 (P =. 25), respectively higher odds of knowing (1) the recommended gestation period for starting ANC, (2) the recommended number of ANC visits, and (3) the timing and frequency of recommended human immunodeficiency virus (HIV) testing, respectively, compared to those in the routine care arm. All women in the MatHealth App arm exclusively breastfed their babies, and brought them at 6 weeks for HIV testing, compared to the routine care arm. Just over half of the women attended at least 4 prenatal visits across the 2 arms. The main reason for noncompliance to ANC appointments was a lack of transport to the clinic. Discussion and conclusion: The app increased knowledge and practices although not reaching statistical significance. Future efforts can focus on addressing social and economic issues and assessing clinical outcomes. This article reports a quantitative evaluation of a mixed-methods trial ({“type”:”clinical-trial”,”attrs”:{“text”:”NCT04089800″,”term_id”:”NCT04089800″}}NCT04089800) composed of pregnant women who were enrolled, randomized 1:1 to receive a maternal health app versus routine care, and followed until 6 weeks after delivery. The methodology for this study has been described previously.15 Pregnant women were recruited from Mbarara Regional Referral Hospital (MRRH), which is the largest hospital in rural southwestern Uganda. The MRRH employs 11 obstetricians and 22 midwives and performs over 10 000 deliveries annually with a maternal mortality rate of 270/100 000 live birth, a cesarean section rate of 30%, and a perinatal mortality rate of 56/1000. In routine care, sociodemographic and basic health data are captured from pregnant women during their first visit and stored in paper-based antenatal registers. Each woman is given an ANC card that contains her biographical data and the date of the next appointment. Women are expected to attend at least 8 ANC appointments with the first contact expected within the first 12 weeks of pregnancy, and they are advised to bring their ANC cards at every visit. The clinic verbally provides group-based maternal health talks to pregnant women scheduled according to the trimester—first-trimester talks are offered on Tuesdays, second-trimester talks are offered on Wednesdays, and third-trimester health talks are offered on Thursdays. Topics covered in these talks include nutrition and birth preparedness based on the MoH guidelines on maternal health.16 There is currently no follow-up mechanism for pregnant women who miss ANC appointments and no provision for remote consultation of healthcare providers. Between January and December 2019, we recruited pregnant women receiving ANC from MRRH into the study. Inclusion criteria were as follows: (1) initiating ANC at MRRH with a first presentation in the first- or second trimester, (2) not having attended school or having limited education (ie, not having studied beyond primary 7 elementary education), (3) 18 years and above, (4) residents of Mbarara (within 20 km of MRRH), (5) ability to use mobile phones, (6) willing and able to give informed consent, and (7) able to speak Runyankole (the local language). We excluded women who were not able or willing to give informed consent. This study was approved by the Institutional Review Committee of Mbarara University of Science and Technology (No: 30/04-18) and the Uganda National Council for Science and Technology (No: SS4661). All participants provided signed informed consent before study participation and were informed at enrollment about their right to refuse/withdraw from the study at any time without any penalty or losing the benefits they were entitled to at the hospital. The maternal and child health application (or MatHealth App) was developed using the Java programming language, while the database that hosts multimedia messages was developed using SQLite. It is an offline (stand-alone) application that does not run on the internet. The video/audio contents are loaded in the app before it is installed on the participants’ phones. On a monthly basis, the app displays notifications of new offline videos tailored to each woman’s stage of pregnancy which is pre-set within the app. The development of the MatHealth App followed an iterative approach that involved engaging potential users (women and healthcare providers) in a series of focus group discussions (FGDs) to suggest and review the app designs.17,18 These discussions included letting the prospective users suggest the content of messages, as well as practically logging in and navigating the app. Each FGD informed the further refinement of the app until users reported being comfortable and comfortable with the design. A pictorial password enabled access to the application. The app was installed on relatively low-cost smartphones (∼60 US dollars) provided by the project at enrollment. The MatHealth was developed to run on android smartphones due to multimedia video and audio compatibility. Women were provided with solar electricity chargers given otherwise limited electricity access. The app has 3 major functionalities: A simple random number generator (https://www.random.org/) was used to determine the study arm assignments of the participants. After screening and consenting, participants were randomized 1:1 to the MatHealth App versus routine care. Each participant in the MatHealth App arm received a relatively low-cost smartphone with the app installed on it. Participants were informed that they could retain the phones after the study closure. A trained research assistant and the app developers explained and demonstrated how the app works including how to log in to access the app, view the multimedia videos and audios, set antenatal appointment reminders, call to talk to the obstetrician, and charge the phone. Participants were then asked to explain what the app does and practically demonstrate how it works. From a private space at a research office near the MRRH, research assistants (WT and ATM) administered a pre-tested structured questionnaire in Runyankole language, to assess maternal and child health-related knowledge and practices to both the MatHealth App arm and the routine care arm at baseline and study exit. Multiple-choice questions were used to assess maternal health knowledge, including (1) the recommended gestation period for starting ANC, (2) the number of ANC visits recommended, and (3) the timing and frequency of HIV testing. The questionnaires included some open-ended questions (such as questions about challenges to accessing ANC). Self-reported questions (expecting yes or no response) were used to ascertain whether women were escorted to the clinic for delivery. Also, we used surveys to collect information on sociodemographics, socioeconomic status, food security, and basic health. (See Supplementary Appendix for details of the questions used.) No metadata were available on app usage because it was used offline as a standalone app. Each survey lasted between 30 and 40 min. We reviewed clinic records from MRRH to capture practices, including ANC visit attendance, health facility-based delivery, and the baby’s attendance at 6 weeks for HIV testing (for women living with HIV). Descriptive statistics were used to compare participants’ sociobehavioral characteristics, basic health data, and maternal and child health-related practices of the study participants across the study arms. We estimated the difference in odds using logistic regression comparing the odds of having maternal and child health-related knowledge at baseline and study exit for both arms. A P-value of <.05 was considered to indicate a significant difference in the mean scores. We chose to carry out a protocol analysis (rather than an intention-to-treat analysis) to avoid making assumptions about knowledge. Open-ended questions were assigned numerical codes and analyzed quantitatively.19 All analyses were done using STATA 13 (StataCorp, College Station, Texas, USA).