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Randomized Controlled Trial
, 9 (2), 0204249

Use of Mobile Technology by Frontline Health Workers to Promote Reproductive, Maternal, Newborn and Child Health and Nutrition: A Cluster Randomized Controlled Trial in Bihar, India

Randomized Controlled Trial

Use of Mobile Technology by Frontline Health Workers to Promote Reproductive, Maternal, Newborn and Child Health and Nutrition: A Cluster Randomized Controlled Trial in Bihar, India

Suzan L Carmichael et al. J Glob Health.


Background: mHealth technology holds promise for improving the effectiveness of frontline health workers (FLWs), who provide most health-related primary care services, especially reproductive, maternal, newborn, child health and nutrition services (RMNCHN), in low-resource - especially hard-to-reach - settings. Data are lacking, however, from rigorous evaluations of mHealth interventions on delivery of health services or on health-related behaviors and outcomes.

Methods: The Information Communication Technology-Continuum of Care Service (ICT-CCS) tool was designed for use by community-based FLWs to increase the coverage, quality and coordination of services they provide in Bihar, India. It consisted of numerous mobile phone-based job aids aimed to improve key RMNCHN-related behaviors and outcomes. ICT-CCS was implemented in Saharsa district, with cluster randomization at the health sub-center level. In total, evaluation surveys were conducted with approximately 1100 FLWs and 3000 beneficiaries who had delivered an infant in the previous year in the catchment areas of intervention and control health sub-centers, about half before implementation (mid-2012) and half two years afterward (mid-2014). Analyses included bivariate and difference-in-difference analyses across study groups.

Results: The ICT-CCS intervention was associated with more frequent coordination of AWWs with ASHAs on home visits and greater job confidence among ASHAs. The intervention resulted in an 11 percentage point increase in FLW antenatal home visits during the third trimester (P = 0.04). In the post-implementation period, postnatal home visits during the first week were increased in the intervention (72%) vs the control (60%) group (P < 0.01). The intervention also resulted in 13, 12, and 21 percentage point increases in skin-to-skin care (P < 0.01), breastfeeding immediately after delivery (P < 0.01), and age-appropriate complementary feeding (P < 0.01). FLW supervision and other RMNCHN behaviors were not significantly impacted.

Conclusions: Important improvements in FLW home visits and RMNCHN behaviors were achieved. The ICT-CCS tool shows promise for facilitating FLW effectiveness in improving RMNCHN behaviors.

Conflict of interest statement

Competing interests: The authors completed the Unified Competing Interest form at (available upon request from the corresponding author), and declare no conflicts of interest.


Figure 1
Figure 1
Description of core features of the ICT-CCS intervention by objective, and the core interventions of the Ananya program that were supported by the ICT-CCS intervention. ICT-CCS – Information Communication Technology Continuum of Care Service, FLW – frontline worker.
Figure 2
Figure 2
Description of the design and sample selection for the ICT-CCS (Information Communication Technology Continuum of Care Service) intervention trial in Saharsa, Bihar 2012-2014. *If a large village (≥150 households, as identified by CARE) was selected, we then organized the village into approximately equal-sized segments (75 to 150 households per segment) and randomly selected one segment of the village for surveying.

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