Designing an impact evaluation for a mobile phone application for nutrition service delivery in Indonesia

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1 Designing an impact evaluation for a mobile phone application for nutrition service delivery in Indonesia Inka Barnett, PhD Barbara Befani, PhD Dr Sigit Sulistyo 15 th October CDI Development Seminar, UEA

2 Overview Review of evidence on mobile phones for nutrition and aims of the evaluation Overview of child nutrition in Indonesia Brief introduction to the mobile phone application Objectives and challenges for the evaluation design Evaluation design for two different components of the nutrition service delivery

3 Mobile phone for nutrition Mobile phones may offer new opportunities to tackle under-& overnutrition Support nutrition service delivery including child growth monitoring & nutrition counselling Large number of descriptive studies & small-scale pilot studies, no integration in national nutrition strategies and low sustainability NO impact evaluation studies!

4 Partnership between WV and IDS Aims to address this evidence gap on the impact of mobile phone technology for nutrition by evaluating the use of a mobile phone application for monthly child growth monitoring and homebased nutrition counselling.

5 Why Indonesia (I)? Child undernutrition remains high in Indonesia, despite steady decline since million children are stunted (too short-for-their-age) and 2.8 million are wasted (too thin-for-their-height), which is globally ranked on place 5 and 4. UNICEF 2013

6 Why Indonesia (II)? In parallel child overweight and obesity increase steadily with 3 million children being overweight UNICEF 2013

7 The Mobile Phone application Developed by WV together with M&B Gates Foundation, Grameen Foundation & Dimagi Smart phones with an Android platform Growth monitoring (registration, collection of anthropometric data, calculation of z-scores, nutritional status and growth velocities, transfer data to database, aggregates data) Nutrition counselling (aids assessment & analysis of underlying reasons for child undernutrition, provides tailored messages)

8 Objectives of the evaluation 1. Examine the impact of the mobile phone application on growth monitoring: Assess the impact on data accuracy and timeliness of data submission (Explore the impact on real-time responsiveness to nutrition data during the monthly sessions Explore the effect on responsiveness by the government & stakeholders) 2. Assess the impact of the mobile phone application on the quality of home-based nutrition counselling

9 Context of the evaluation 14 study sites in Indonesia (10 rural and 4 urban) Facility-based pilot (each facility (posyandu) receives 1 mobile phone to be used for monthly growth monitoring & nutrition counselling) In all sites paper-based and mobile phone-based nutrition service delivery 12 months pilot

10 Development of the evaluation design February 2014 initial scoping visits to urban and rural sites in Indonesia to get to know: The context Challenges in growth monitoring and nutrition counselling that the mobile application would address (important to identify indicators and outcomes) Current procedures in 14 monthly health posts (posyandu) in which the mobile application will be tested

11 Challenges to the choice of evaluation design 1. Sites selection: Study sites had been selected already by WV (14 posyandus = no random selection possible, not representative) 2. Growth monitoring: It was impossible to replace the current paperbased growth monitoring with mobile phone-based monitoring due to government regulations (= mobile phone application has to be introduced in parallel to the paper-based data collection) 3. Nutrition counselling: Only mothers with undernourished children received counselling (2-6 per months, often repeated) Impossible to use common causal inference model for the impact evaluation (RCT, experimental designs) Need to choose alternative designs!

12 Other challenges Data collection by WV staff (huge risk of bias) High turn over of cadres (nutrition volunteers) New ethical approval procedures in Indonesia

13 Evaluation design Formative evaluation phase (first 2-3 months, ongoing) : - Technology acceptability assessment - Context assessment - Functionality of the mobile application Summative phase (10-12 months, November): 1. Growth monitoring component Accuracy and timelines of submission: Mill s Method of Difference (Responsiveness during posyandu (i.e. immediate feedback): Mill s Method of Difference & realist approach Responsiveness to the data by stakeholders: political economy analysis & stakeholder interviews) 2. Nutrition counselling component Improvement of quality of nutrition counselling: Process tracing

14 Theory of change

15 Evaluation of the mobile phone for growth monitoring

16 Procedures for growth monitoring

17 Threats to data accuracy Doubts about the accuracy of the growth monitoring data is a major reason for why data is not used by local, regional & national policymakers Three areas of threats to data accuracy: Data entry (repeated manual transfer) (desk 2, 3, 4) Plotting and interpretation (desk 3) Aggregation for summary reports (desk 3, 4, 5) Evaluation question: How much does the mobile phone application improve data accuracy of growth monitoring during (1) data entry, (2) data plotting and (3) data aggregation for reports?

18 Plotting and interpretation

19 Summary report

20 Threats to timeliness Data submission using traditional paper-based records is often time-consuming & data is frequently out-ofdate & not useful any longer Mobile phone can submit individual level data in and summary reports in real-time Evaluation question: How much does the mobile phone improve timeliness of data submission compared to the traditional paperbased system?

21 Challenges for the assessment of accuracy & timeliness No comparison of growth monitoring with and without mobile phone possible due to government regulations! Both types of data collection have to be conducted in parallel

22 Mill s Method of Difference

23 In practices that means (I) The mobile phone application and the traditional paper-based data collection are conducted simultaneously for the same child The resulting records are then compared with regards to data accuracy and timeliness

24 With the mobile phone

25 Evaluation of the mobile phone for nutrition counselling

26 Procedure for nutrition counselling Home-based nutrition counselling is conducted by cadres only for children that are identified as undernourished (approximately 2 to 6 per posyandu) Counselling follows UNICEF instructions for homebased counselling (with some adaptations for Indonesian MOH) 3-step approach: 1. Assess (behavioral patterns and hh-specific barriers to child nutrition) 2. Analyze information given by mother 3. Act (provide tailored specific messages)

27 Mobile phones for nutrition counselling Mobile phone application can potentially strengthen each step: 1. Ensuring a comprehensive initial assessment (via a brief interactive survey and prompts) 2. Analysis information provided in assessment 3. Act: Provision of specific information Evaluation questions: How does the mobile phone improve the quality of nutrition counselling with regards to: 1. Initial assessment 2. Analysis of information provided 3. Provision of information

28 Challenges for the evaluation of mobile phones for nutrition counselling Small group of children/mother pairs who receive counselling in each posyandu/month (i.e. randomisation, comparison meaningless as very small sample size, no matching possible) Counselling is very specific and focuses on household-level barriers to child nutrition (i.e. comparison of knowledge of mothers who received counselling with and without mobile phone meaningless)

29 Process tracing Process tracing to unwrap whether, why and how the mobile phone may improve the different steps of the counselling 3 Hypotheses were developed based on initial observations of the counselling process with and without mobile phone and interviews of several cadres about their practices and challenges during the counselling process

30 Hypotheses for the process tracing The mobile phone will. 1. Improve 2. Not change 3. Worsen the (1) the initial assessment; (2) analysis and (3) provision of tailored behaviour change messages during the home-based counselling.

31 Process tracing Each hypothesis will be systematically tested using two guiding questions for the collection of diagnostic evidence 1. What would we expect to observe if the hypothesis is true (improvement, no relevant change, worsening)? 2. What / which observation(s) would be very unlikely UNLESS the hypothesis is true (what observations would practically prove the hypothesis because they're extremely unlikely under any other circumstance)?

32 Process tracing tools Direct observations of counselling sessions with a checklist (cadres behaviour, attitude and interaction with the mother, includes baseline of counselling sessions without mobile phone to identify outcome indicators) Interviews with cadres Interviews with mothers Technical checklist for the features of the mobile phone application

33 Thank you For further questions Inka Barnett

34 How mobile phone may improve initial assessment during counselling. Mobile gives structure and avoids missed steps Gives confidence to the cadres in assessment Accuracy of assessment improved Quicker as less time needed for initial assessment (cadres are less likely to talk about other unrelated things with mother) More participatory and mothers engage more (want to see what is on screen) Mothers perceive it as more important and serious and pay attention Makes sure that mothers are regularly praised and rewarded for good practices (phone includes reminders) Skills of cadres are improved as the see assessment questions over and over in the application

35 How mobile phone may worsen initial assessment during counselling. List of questions takes very long to administer and mother gets angry and attention drops Cadre s attention during the initial assessment is on phone only (does not build good report with mother) Closed questions, cadres don t believe mothers yes/no answers (cadres know mothers better and expect social desirability bias in their answers (especially as mothers fear that cadre will send their answers to the MoH) Informal conversation during the initial assessment gets lost and cadres don t build trust in cadre with mothers No preparation for individual child before home visit necessary (own initiative of cadres reduced)

36 Mill s Method of Difference The cause for the illness must be the consumption of the salad as all other items taken were the same. Similar the cause for the difference between the records must be the phone as all other characteristics are the same)

37

38 Work plan for EACH posyandu

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