Lessons Learnt from Applying a Human-Centred Design Process to Develop One of the Largest Mobile Health Communication Programmes in the World

"A global conversation has been unfolding for decades about how to effectively approach and structure the human-centred design (HCD) process to solve complex problems..."

Experience shows that digital solutions are more likely to be effective if the intended users are involved in the design process. Building on its own experience of applying human-centred design (HCD) approaches to tackle systemic developmental challenges, BBC designed a digital behavioural change communication (BCC) programme to strengthen families' reproductive, maternal, newborn, and child health (RMNCH) practices and to generate demand for public health services in the north Indian state of Bihar between 2011 and 2013. Two of the solutions were later adopted by the government and scaled to 10 million subscribers and more than 300,000 frontline health workers (FLHWs) in 13 states. This paper describes the process undertaken to design these digital solutions, highlighting lessons learned and considerations that may be useful for others who are designing digital health solutions in low-and-middle-income countries (LMICs).

To accelerate progress towards the state of Bihar's goal of reducing maternal and infant mortality, BBC Media Action, through an initiative (called "Ananya", Hindi for "unique") with the state government and the Bill & Melinda Gates Foundation, began work in 2011 to stimulate demand for public health services and strengthen the practice of 11 priority health behaviours that are proven to save lives. BBC Media Action worked to design communication solutions using a 5-stage HCD approach:

1. Empathise: To design Mobile Academy, Mobile Kunji ("key" in Hindi) and Kilkari ("baby's gurgle" in Hindi), a team consisting of social and behavioural change communication specialists, health experts, researchers, and creative and digital strategists and designers used a range of techniques (e.g., a survey) to observe, engage, and immerse themselves in the lives of FLHWs, rural women, and their families in Bihar. This step helped the team gain an understanding of the "lived experiences" of economically poor, rural women - from girlhood through to motherhood.
2. Define: The team analysed qualitative and quantitative data from the formative research described in stage 1 to define the problem. As part of this process, the team identified the following barriers to changes in health practices at scale: inequalities in health access; existing social norms around key target behaviours (e.g., women's bodies as impure, pregnancy and childbirth as "women's issues", family planning as a taboo topic); limited agency among new and expecting mothers; decision-making and access to phones controlled by gatekeepers in the family; basic phones and low digital literacy; limited time and job aids for FLWHs to build their skills; and deficiencies in the public health system that posed a challenge to shaping demand and practice.
3. Ideate: Guided by learnings from stages 1 and 2, the team developed an overarching theory of change based on the hypotheses that: (i) providing timely, accessible, accurate, and relevant information improves knowledge; (ii) however, while knowledge is necessary, it is insufficient to change behaviour; (iii) negotiations between FLHWs and families are critical to improving the self-efficacy of families; (iv) discussion is often a gateway to change; and (5) increased knowledge and better interpersonal communication skills will make FLHWs more confident and motivated. Ideas were generated through a series of brainstorming sessions for a complementary suite of digital solutions for FLHWs and families to support pathways to change. In addition to digital solutions for FLHWs, ideas were generated for digital communication solutions to reinforce the information shared by FLHWs with families and to send timely reminders about critical health practices.
4. Prototype: The ideation phase resulted in prototypes for a suite of 3 mHealth services: Mobile Academy, a training course to refresh FLHWs knowledge of RMNCH behaviours and improve their interpersonal communication skills; Mobile Kunji, a job aid to support FLHWs' interactions with families; and Kilkari, a mobile messaging service that delivered weekly, stage-based, time-sensitive audio information directly to the phones of pregnant women, new mothers, and their families to reinforce FLHWs' counselling. The content of the mHealth services was narrated by one voice: Dr Anita, a character who was designed to act as a friend, philosopher, and guide.
5. Test: The team qualitatively tested paper-based prototypes, consisting of accessible summaries of the concepts for each service and sample audio content, with FLHWs and families via in-depth interviews to explore and assess user demand and willingness to pay for each of the mHealth services. Then, a portable, low-tech laboratory was used to iteratively engage with FLHWs and low-literate pregnant women and mothers in 8 districts in Bihar to test the IVR prototypes.

The socio-ecological model provides a conceptual framework for understanding key learnings from the HCD process:

• At the organisational level, the team found that demand generation was constrained by deficiencies in the public health system.
• At the community level, gender norms were a barrier to changing health practices.
• At the interpersonal level, mobile health solutions for mothers also had to address fathers, because they controlled women's access to mobile phones.
• At the individual level, two examples include: Users with few digital skills struggled with long interactive voice response (IVR) menus and could not use hierarchical IVR menus at all (they found it easier to use linear IVR navigation); and an authoritative yet empathetic narrator was required to humanise the digital experience, lend credibility, and create engagement.

After the services were piloted with 50,000 FLHWs in Bihar, and research studies revealed a positive impact on multiple health outcomes, Mobile Academy and Mobile Kunji were scaled to Odisha and Uttar Pradesh in collaboration with state governments. The national scale-up of Mobile Academy and Kilkari began in January 2016. Over the next 3 years, the government scaled the services to 13 states with BBC Media Action's support. (Mobile Kunji was not scaled by the national government because it was thought that FLHWs would soon have personal smartphones.) By 2019, when BBC Media Action made its planned exit from the programme, 206,000 FLHWs had graduated from Mobile Academy, and Kilkari had reached 10 million subscribers, who had listened to more than 200 million minutes of content.

"These results suggest that HCD processes, when effectively applied, can be invaluable in creating impactful digital solutions that resonate with communities and have a strong potential for scale, sustainability and health system integration."