MANTRA: Increasing maternal and child health resilience before, during and after disasters using mobile technology in Nepal

Lead Research Organisation: University College London
Department Name: Inst for Risk and Disaster Reduction

Abstract

In emergency situations, women of childbearing age do not stop becoming pregnant or giving birth. However, humanitarian emergencies often negatively impact health care systems, through damaged or destroyed critical infrastructure which restrict perinatal women and their newborns access to reproductive and maternal health care. This is particularly the case in rural remote regions, such as mountainous areas of Nepal, where frequent earthquakes and landslides pose significant hazards to an already limited healthcare infrastructure.
Understanding the needs of perinatal women and newborns in emergencies and developing adequate interventions to increase their resilience (i.e. their capacities to protect themselves and recover), should be part of any Disaster Risk Reduction (DRR) planning or response and yet these needs are often unmet. In such crises, Female Community Health Volunteers (FCHVs), who generally support mothers and encourage them to seek care in the perinatal period, may themselves be cut off from the health facilities that they serve and may be struggling to cope in the same way as other community members. Urgently needed information and knowledge may exist but be inaccessible for a number of reasons including: inappropriate use of technical language, text-based information inaccessible to those with low or no literacy, denigration of local knowledge, restrictions on the freedom of movement or access to communications of women and girls, and infrastructure damage that obstructs travel to and from healthcare services.
Empowering women to improve their health has been successfully implemented by UCL IGH, in partnership with Nepalese NGOs, by training FCHVs to run participatory learning and action women's groups focused upon maternal and newborn health. This community-based intervention was found to reduce mortality in the first month of life (i.e. during the neonatal period) by 30% in Nepal (Manandhar at al 2004) and has been effective in reducing neonatal and maternal mortality (Prost et al 2013). However, to date this approach has not been oriented towards resilience during emergencies, and neither has it been adapted to take advantage of the rapid growth in access to mobile technology in developing countries.
Therefore, this project investigates how to improve access to information and communications to support maternal and child health before, during and after a disaster. It aims to do this by developing mobile technology to support and expand existing participatory learning public health interventions and social protection mechanisms, especially in rural areas of Nepal. By doing so, this initiative addresses some of the priorities highlighted in the UN Sustainable Development Goals, and the Sendai Framework for Disaster Risk Reduction 2015-2030 to support maternal, newborn and child health, as well as sexual and reproductive health.
This research combines geosciences (e.g. scientific knowledge of natural hazards and risk assessments based on satellite imagery), social sciences (e.g. attention to gender, vulnerability and health in the context of disasters), technology (e.g. mobile apps) and arts (e.g. through participatory learning, and visual and textual health care communications) to devise new ways of rapidly deriving data from satellite interpretation and fieldwork that can be developed into a meaningful risk interpretation for local communities. Through adding a mobile phone 'app' the objective of this project is to make evidence-based information (e.g. oral survivor accounts, locally-generated photographs, drawings, videos, stories, and historical recollections) and learning wider-reaching and accessible, especially when paper booklets or picture cards might be unavailable or damaged and when disasters have cut off lifeline infrastructure.

Planned Impact

In 2015, Nepal has suffered a devastating earthquake that killed nearly 9,000 people, injured 22,500 and left 800,000 in need of shelter. The Health Research and Social Development Forum (HERD) has been working with rural women and FCHV communities during and after the 2015 earthquake to assess the risk and deliver health services. Dr Hearn who worked in Nepal port earthquake also identified there is little or no information available to guide communities as to the hazard posed by slopes during and after disasters making perinatal women who need access to healthcare extremely vulnerable. Further, maternal health and especially perinatal women are often overlook in disaster planning. However, 20% of women of childbearing age are likely to be pregnant during emergencies (UNFPA 2012). Perinatal women and newborns are particularly vulnerable during and after emergencies when critical infrastructure may be damaged, destroyed or otherwise difficult to access (Menendez et al., 2015; Mupapa et al., 1999; Kobayashi et al 2016).

Based on this context and demand, the project intended impacts aim to support:
1. The Nepalese government, NGOs, HERD, MIRA and other organisations dealing with health, maternal and newborn populations and environmental hazards and resilience. They will benefit through promoting their economic development and welfare by building resilience based on new knowledge about environmental hazards, better understanding of rapid landslides risk assessment using satellite imagery and the use of mobile technology for communication risk and grass root support. Combining scientific evidence, local informal knowledge and experience with a new mode of delivery - mhealth - has proven useful in remote areas where the availability of functioning health systems is minimal (Gray, 2013). Novel, original, scientific interdisciplinary results, from the data collected and the methodologies developed and tested will be documented through publications, workshops and exhibitions.
2. Women, newborns, FCHVs, communities in rural and high risk areas who will be actively involved in this project from collection of images, co-authoring of the technology app and evaluation of the pilot. A follow up proposal is planned to develop the approach and scale it up across Nepal to increase women's resilience, in particular the vulnerable perinatal group and newborns, to environmental hazards.
3. The UK's government and NGOs dealing with building resilience to environmental hazards and gender issues. They will benefit through ensuring that ODA has a significant and positive impact on the economic development and welfare and through the collaborations and partnerships built during this project.

Publications

10 25 50
 
Title MANTRA Films pf Women's Stories 
Description Three films were made by Nepali Photographer Dinesh Deokota of Media for Development. These were three women's stories from the time of the 2015 earthquake in Nepal. 
Type Of Art Film/Video/Animation 
Year Produced 2017 
Impact Rural women, some of whom are illiterate, rarely get to tell their stories. They certainly do not often have films made of themselves. THis had an impact on the women's self esteem as well as bringing home clearly their experiences to government and other stakeholders who do not often get to hear first hand in this way. 
URL https://www.ucl.ac.uk/rdr/research/ongoing-projects/mantra/
 
Title MANTRA PhotoVoice 
Description 10 photo images of women plus 10 photo images of significant objects or locations they specified plus their 'story'. These were exhibited in Kathmandu and in London. In Kathmandu they were accompanied with audio versions of the women's stories in their own language. 
Type Of Art Artwork 
Year Produced 2017 
Impact The Photovoice display was particularly well received by Government and NGO stakeholders at the project Workshop in Nepal because they were the aiuthentic voices of the woemn in their own language and not mediated accounts from researchers. 
 
Description Documented experiences of perinatal women (during earthquake) and their support persons, Female Community Health Volunteers (FCHVs), community leaders and health workers, in two communities with significant earthquake/landslide damage and ongoing risk. This included stories of women experiencing the 2015 Gorkha earthquake and hazardous environments in their everyday lives through film, voice and photographic images. New or improved research methods or skills developed - the MANTRA project was successful in establishing a transdisciplinary, gender-responsive, participatory and culturally-rooted approach to Disaster Risk Reduction (DRR), and maternal and child health. New research networks/collaborations/partnerships were established (some of the individual researchers, research and practice organizations had never worked together before) because of the specific mix of approaches (gender, DRR, computer science, health social science, PhotoVoice / film-making and geoscience) and the novel outputs (film, photo image and mobile app). In country partners had not considered working in such a multidisciplinary way before.
At the community level, the project provided an opportunity for local women and Female Community Health Volunteers to use mobile phones to gain information through a serious games approach. Many of the women had never handled a smartphone before, believing them to be too complex for someone with no or low literacy/numeracy. But through enjoyment in learning socially in groups, there was greater engagement with health and environmental risk information.
The Lead Nepal Co-I able was able to establish a better collaborative relationship with different organizations including government and local rural communities.
The Lead Nepal Co-I was able to transfer methodological knowledge gained in this award to another health
Exploitation Route The serious game app developed for the project can be taken forward by in-country researchers and applied to similar and other areas. Local research partners can take advantage of the interest shown by government and other stakeholders which was generated through an international project. The research process we used to work collaboratively and engage local community members, e.g. in evaluation of the app through various stages, is a good practice to be recommended. The engaging presentation through film and PhotoVoice of the experiences of pregnant and newly delivered women can be used to raise awareness of service delivery gaps for these highly vulnerable groups before, during and after disaster. The Photo Voice method has been found to have wider applications in follow up work.
The follow up research with policy and decision makers on the new Disaster Management Act in Nepal was a small qualitative piece of work with a small funding amount. There is much more to be done on this which we are currently planning for a larger, MANTRA2 submission shortly.
Sectors Communities and Social Services/Policy,Digital/Communication/Information Technologies (including Software),Education,Environment,Healthcare,Other

URL https://www.ucl.ac.uk/risk-disaster-reduction/research-projects/2019/feb/mantra
 
Description The Ministry of Health, Government of Nepal said publicly in our final Workshop they were "ready to take this further". Our Nepal partners have used the methods they learned from MANTRA in other health awareness interventions.
First Year Of Impact 2018
Sector Healthcare,Other
Impact Types Societal,Policy & public services

 
Description Increasing Resilience to Environmental Hazards in Border Conflict Zones 
Organisation University College London
Country United Kingdom 
Sector Academic/University 
PI Contribution MANTRA team members contributed to the Increasing Resilience to Environmental Hazards in Border Conflict Zones, Ladakh network building workshop and field exercise. Network building with Ladakh government (India), University of Jammu, Ladakhi schools, etc. though participation in regional workshop and schools outreach programme. The MANTRA team could bring new, gendered, public health and geoscience knowledge as well as expertise in working ethically and creatively at the community level.
Collaborator Contribution Sharing knowledge and experience gained in a different geographic and cultural location. Sharing insights from hazard awareness raising and knowledge exchange.
Impact Successful schools education programme involving several hundred school children. Improvement to the Ladakh disaster management plan. This is a multidisciplinary collaboration. Disaster and Risk Management, Geoscience, Education, Social Science, International Affairs, Gender Theory, Computer Science, Health, Film-making.
Start Year 2017
 
Title MANTRA app 
Description The Mantra serious game application was developed for the first time using a Unity 3D software technology. It is a game for public health education. It is designed to improve the level of health knowledge among rural Nepalese women by teaching them how to assess the level of danger posed by various situations. Because of the lack of literacy skills, the player has to make choices and progress through the game via an entirely graphical interface (as verbal cues are not used). It is a "point and click" style of mobile game with drag-and-drop style interactions. It features three playable categories: maternal health, neonatal health and geohazards. 
Type Of Technology Webtool/Application 
Year Produced 2017 
Impact The app was evaluated by 50 participants (ages 20 to 60) in two key groups: Female Community Health Volunteers (24 participants) and Community women (26 participants). Evidence from three evaluation exercises showed increased learning for many of the app objectives (increased success ratios and increased scores). The women, many of them older and unused to smartphones, enjoyed the learning experience and gained self esteem (now they understood why their younger family members spent so much time looking at their phones - because it was fun). The process indicated the value of using this technology for public health and risk information and education. Unfortunately, the Mantra game is not available for public access due to lack of ongoing funding to keep it running. 
URL https://www.ucl.ac.uk/rdr/research/ongoing-projects/mantra/
 
Description MANTRA Consultative Workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact A Consultative Workshop was convened on November 7th 2017 in the Summit Hotel, Kathmandu, Nepal, to engage a mixed stakeholder group with the outputs of MANTRA and to consider 'Opportunities in humanitarian emergencies to strengthen readiness, response and recovery for perinatal women' in breakout groups. The stakeholders included Government of Nepal representatives, International, National and Local NGOs. Around 15 stakeholders attended. A larger number of people, including members of the general public, joined the Workshop invitees to view films and PhotoVoice materials in an open air exhibition. The aim was to share the outputs of the project in a series of presentations, and to engage discussions on the next phase of MANTRA development on the (subsequently mistaken) expectation that there would be opportunities for follow-on funding. The Workshop members were critical friends to the project and provided suggestions and advice as well as praise. There was overwhelming support for the project, its achievements and its future possibilities for development in Nepal. One participant said "the information you have is very rich". Another, Government of Nepal participant said "the Government of Nepal, Ministry of Health is ready to take this further". THere was considerable interest in how mobile apps can be used to convey important health and environmental risk information to a range of community members in Nepal.
Year(s) Of Engagement Activity 2017
URL https://www.ucl.ac.uk/rdr/research/ongoing-projects/mantra/