mHealth intervention “ImTeCHO” to improve delivery of maternal, neonatal, and child care services—A cluster-randomized trial in tribal areas of Gujarat, India

Autoři: Dhiren Modi aff001;  Nishith Dholakia aff002;  Ravi Gopalan aff003;  Sethuraman Venkatraman aff003;  Kapilkumar Dave aff001;  Shobha Shah aff001;  Gayatri Desai aff001;  Shamim A. Qazi aff004;  Anju Sinha aff005;  Ravindra Mohan Pandey aff006;  Ankit Anand aff007;  Shrey Desai aff001;  Pankaj Shah aff001
Působiště autorů: Community Health Department, SEWA Rural, Jhagadia, Bharuch, Gujarat, India aff001;  Commissionerate of Health, Government of Gujarat, Gandhinagar, Gujarat, India aff002;  Argusoft India Ltd., Gandhinagar, Gujarat, India aff003;  Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland aff004;  Division of Reproductive Biology, Maternal & Child Health, Indian Council of Medical Research, New Delhi, India aff005;  Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India aff006;  Population Research Centre, Institute of Social and Economic Change, Bengaluru, India aff007
Vyšlo v časopise: mHealth intervention “ImTeCHO” to improve delivery of maternal, neonatal, and child care services—A cluster-randomized trial in tribal areas of Gujarat, India. PLoS Med 16(10): e32767. doi:10.1371/journal.pmed.1002939
Kategorie: Research Article
doi: 10.1371/journal.pmed.1002939



The coverage of community-based maternal, neonatal, and child health (MNCH) services remains low, especially in hard-to-reach areas. We evaluated the effectiveness of a mobile-phone–and web-based application, Innovative Mobile-phone Technology for Community Health Operations (ImTeCHO), as a job aid to the government’s Accredited Social Health Activists (ASHAs) and Primary Health Center (PHC) staff to improve coverage of MNCH services in rural tribal communities of Gujarat, India.

Methods and findings

This open cluster-randomized trial was conducted in 22 PHCs in six tribal blocks of Bharuch and Narmada districts in India. The ImTeCHO mobile-phone–and web-based application included various technology-based job aids to facilitate scheduling of home visits, screening for complications, counseling during home visits, and supportive supervision by PHC staff. Primary outcome indicators were a composite index calculated based on coverage of important MNCH services and coverage of at least two home visitations by ASHA within the first week of birth. Primary analysis was intention to treat (ITT). Generalized Estimating Equation (GEE) was used to account for clustering. Eleven PHCs each were randomly allocated to the intervention (280 ASHAs, population: 234,134) and control (281 ASHAs, population: 242,809) arms. The intervention was implemented from February, 2016 to January, 2017. At the end of the implementation, 6,493 mothers were surveyed. Most of the surveyed women were tribal (5,571, 85.8%), and reported having a government-issued certificate for living below poverty line (4,916, 75.7%). The coverage of at least two home visits within first week of birth was 32.4% in the intervention clusters compared to 22.9% in the control clusters (adjusted effect size 10.2 [95% CI: 6.4, 14.0], p < 0.001). Mean number of home visits within first week of birth was 1.11 and 0.80 for intervention and control clusters, respectively (adjusted effect size 0.34 [95% CI: 0.23, 0.45], p < 0.001). The composite coverage index was 43.0% in the intervention clusters compared to 38.5% (adjusted effect size 4.9 [95% CI: 0.2, 9.5], p = 0.03) in the control clusters. There were substantial improvements in coverage home visits by ASHAs during antenatal period (adjusted effect size 15.7 [95% CI: 11.0, 20.4], p < 0.001), postnatal period (adjusted effect size 6.4, [95% CI: 3.2, 9.6], p <0.001), early initiation of breastfeeding (adjusted effect size 7.8 [95% CI: 4.2, 11.4], p < 0.001), and exclusive breastfeeding (adjusted effect size 13.4 [95% CI: 8.9, 17.9], p < 0.001). Number of infant and neonatal deaths was similar in the two arms in the ITT analysis. The limitations of the study include potential risk of inaccuracies in reporting events that occurred during pregnancy by the mothers and the duration of intervention being 12 months, which might be considered short.


In this study, we found that use of ImTeCHO mobile- and web-based application as a job aid by government ASHAs and PHC staff improved coverage and quality of MNCH services in hard-to-reach areas. Supportive supervision, change management, and timely resolution of technology-related issues were critical implementation considerations to ensure adherence to the intervention.

Trial registration

Study was registered at the Clinical Trial Registry of India ( Trial number: CTRI/2015/06/005847. The trial was registered (prospective) on 3 June, 2015. First enrollment was done on 26 August, 2015.

Klíčová slova:

Health services administration and management – Child health – Infants – Neonatal care – Neonates – Pregnancy – Surveys – Web-based applications


1. Alkema L, Chou D, Hogan D, Zhang S, Moller A, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Lancet. 2016; 387: 462–74. doi: 10.1016/S0140-6736(15)00838-7 26584737

2. United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Levels & Trends in Child Mortality: Report 2018, Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation. New York, NY: United Nations Children’s Fund; 2018.

3. Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD007754. doi: 10.1002/14651858.CD007754.pub2 21069697

4. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, deBernis L. Neonatal Survival 2 Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet. 2005; 365: 977–88. doi: 10.1016/S0140-6736(05)71088-6 15767001

5. Campbell OMR, Graham WJ.; Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006; 368: 1284–99. doi: 10.1016/S0140-6736(06)69381-1 17027735

6. McConnell M, Ettenger A, Rothschild W, Muigai F, Cohen J. Can a community health worker administered postnatal checklist increase health-seeking behaviors and knowledge?: evidence from a randomized trial with a private maternity facility in Kiambu County, Kenya. BMC Pregnancy Childbirth. 2016; 16: 136. doi: 10.1186/s12884-016-0914-z 27260500

7. Braun R, Catalani C, Wimbush J, Israelski D. Community Health Workers and Mobile Technology: A Systematic Review of the Literature. PLoS ONE. 2013; 8: e65772. doi: 10.1371/journal.pone.0065772 23776544

8. Hackett K, Lafleur C, Nyella P, Ginsburg O, Lou W, Sellen D. Impact of smartphone-assisted prenatal home visits on women’s use of facility delivery: Results from a cluster-randomized trial in rural Tanzania. PLoS ONE. 2018; 13(6): e0199400. doi: 10.1371/journal.pone.0199400 29912954

9. Chen H, Chai Y, Dong L, Niu W, Zhang P. Effectiveness and Appropriateness of mHealth Interventions for Maternal and Child Health: Systematic Review. JMIR mHealth uHealth. 2018; 6(1): e7. doi: 10.2196/mhealth.8998 29317380

10. Amoakoh-Coleman M, Borgstein AB-J, Sondaal SF, Grobbee DE, Miltenberg AS, Verwijs M, et al. Effectiveness of mHealth Interventions Targeting Health Care Workers to Improve Pregnancy Outcomes in Low- and Middle-Income Countries: A Systematic Review. J Med Internet Res. 2016; 18(8): e226. doi: 10.2196/jmir.5533 27543152

11. Sondaal SFV, Browne JL, Amoakoh-Coleman M, Borgstein A, Miltenberg AS, Verwijs M, et al. Assessing the Effect of mHealth Interventions in Improving Maternal and Neonatal Care in Low- and Middle-Income Countries: A Systematic Review. PLoS ONE. 2016; 11(5): e0154664. doi: 10.1371/journal.pone.0154664 27144393

12. Ministry of Health and Family Welfare. Indian Public Health Standards (IPHS) Guidelines for Primary Health Centres Revised. New Delhi: Government of India, 2012.

13. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010; 375: 1609–23. doi: 10.1016/S0140-6736(10)60518-1 20382417

14. Black R, Causens S, Jhonson H. Global, Regional and National Causes of Child Mortality in 2008. Lancet. 2010; 375: 1969–87.

15. International Institute for Population Sciences I. IIPS and Macro International. National Family Health Survey (NFHS-3), 2005–06: India: volume I. Mumbai, India [Internet; cited 2018 Nov 13].

16. Bajpai N, Dholakia RH. Improving the Performance of Accredited Social Health Activists in India. Work Papers Series Columbia Glob Centers 2011. South Asia, Columbia University, Mumbai, India.

17. Maternal and Child Health Integrated Program (MCHIP). India’s Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH+A) Strategy [Internet]. USAID; 2014 [cited 2017 June 17].

18. National Health Systems Resource Centre (NHSRC). ASHA Which Way Forward: Evaluation of ASHA program 2010–11 Report [Internet; cited 2019 Jan 23]. New Delhi: National Institute of Health and Family Welfare; 2011.

19. Ministry of Tribal Affairs. Report of the high level committee on socioeconomic, health and educational status of tribal communities of India. New Delhi: Government of India; 2014.

20. Ministry of Health and Family Welfare. District Level Household and Facility Survey -3 (DLHS-3). International Institute for Population Sciences I. Mumbai, India, 2014 [Internet; cited 2019 Jan 23].

21. National Health Systems Resource Centre (NHSRC). Evaluation theory and evaluation practice _ in the NRHM context. Berkeley, CA: Center for effective global action, University of California Berkeley; 2014 [cited 2019 Jan 23].

22. Modi D, Gopalan R, Shah S, Venkatraman S, Desai G, Desai S, et al. Development and formative evaluation of an innovative mHealth intervention for improving coverage of community-based maternal, newborn and child health services in rural areas of India. Glob Health Action. 2015; 8: 26769. doi: 10.3402/gha.v8.26769 25697233

23. Modi D, Desai S, Dave K, Shah S, Desai G, Dholakia N, et al. Cluster randomized trial of a mHealth intervention “ImTeCHO” to improve delivery of proven maternal, neonatal, and child care interventions through community-based Accredited Social Health Activists (ASHAs) by enhancing their motivation and strengthening. Trials. 2017; 18: 270.

24. National Health Systems Resource Centre (NHSRC). Update on ASHA program [Internet; cited 2019 Jan 23]. New Delhi, India: National Health Mission, Government of India; 2017.

25. National Rural Health Mission Ministry of Health & Family Welfare. Guidance note for implementation of RMNCH+A interventions in High Priority Districts. New Delhi: Government of India; 2013 [cited 2018 Aug 18].

26. Government of India. List of High Priority Talukas in Gujarat–Community Action for Health. National Health Mission. New Delhi: Government of India; 2014 [cited 2018 Aug 18].

27. Government of India. Census of India 2011 [Internet; cited 2018 Sept 29].

28. Singh KS. People of India: Gujarat Part one Volume XXII. Mumbai: Popular Prakashan; 2003.

29. Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, et al: Framework for the design and evaluation of complex interventions to improve health. British Medical Journal 2000, 321:694–696. doi: 10.1136/bmj.321.7262.694 10987780

30. SEWA Rural. ImTeCHO Demonstration Video. SEWA Rural. Jhagadia [cited 2018 Oct 1].

31. International Institute for Population Sciences. District Level Household and Facility Survey (DLHS-4). Government of India. 2011. Bid for field agency at 1IIPS,Mumbai..pdf. Accessed 18 August 2018.

32. Shah P, Madhiwala N, Shah S, Desai G, Dave K, Dholakia N, et al. High Acceptability and Uptake of an Innovative Mobile-Phone Application among Community Health Workers in Rural Areas of India: An Implementation Research Study. National Medical Journal of India. Forthcoming.

33. Källander K, Tibenderana JK, Akpogheneta OJ, Strachan DL, Hill Z, ten Asbroek AH, et al. Mobile Health (mHealth) Approaches and Lessons for Increased Performance and Retention of Community Health Workers in Low- and Middle-Income Countries: A Review. J Med Internet Res. 2013; 15: e17. doi: 10.2196/jmir.2130 23353680

34. Atnafu A, Otto K, Herbst CH. The role of mHealth intervention on maternal and child healthservice delivery: findings from a randomized controlled field trial in rural Ethiopia. mHealth. 2017; 3: 39–39. doi: 10.21037/mhealth.2017.08.04 29184891

35. Borkum E, Sivasankaran A, Sridharan S, Rotz D, Sethi S, Manoranjini M, et al. Evaluation of the Information and Communication Technology (ICT) Continuum of Care Services (CCS) Intervention in Bihar. Princeton: Mathemetica Policy Research, 2015.

36. Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk BE, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev. 2010;(3): CD004015. doi: 10.1002/14651858.CD004015.pub3 20238326

37. Ciapponi A, Lewin S, Herrera CA, Opiyo N, Pantoja T, Paulsen E, et al. Delivery arrangements for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev. 2017;9: CD011083. doi: 10.1002/14651858.CD011083.pub2 28901005

38. Lee SH, Nurmatov UB, Nwaru BI, Mukherjee M, Grant L, Pagliari C. Effectiveness of mHealth interventions for maternal, newborn and child health in low–and middle–income countries: Systematic review and meta–analysis. J Glob Health. 2016; 6: 010401. doi: 10.7189/jogh.06.010401 26649177

39. Lund S, Boas IM, Bedesa T, Fekede W, Nielsen HS, Sorensen BL. Association between the safe delivery app and quality of care and perinatal survival in Ethiopia: A Randomized Clinical Trial. JAMA Pediatr. 2016; 170(8): 765–771. doi: 10.1001/jamapediatrics.2016.0687 27322089

40. Bolan NE, Sthreshley L, Ngoy B, Ledy F, Ntayingi M, Makasy D et al. mLearning in the Democratic Republic of the Congo: A mixed-methods feasibility and pilot cluster randomized trial using the safe delivery app. Glob Health Sci Pract. 2018;6(4):693–710. doi: 10.9745/GHSP-D-18-00275 30591577

41. World Health Organization (WHO). WHO guideline recommendations on digital health interventions for health system strengthening. Geneva: WHO; 2019 [cited 2019 Jul 28].

42. Prime Minister’s Office. PM visits Vadnagar, launches Intensified Mission Indradhanush, addresses public meeting. Government of India. Bhubaneshwar. Press Information Bureau. 8 October, 2017 [cited 2018 Oct 2].

Interní lékařství

Článek vyšel v časopise

PLOS Medicine

2019 Číslo 10

Nejčtenější v tomto čísle

Tomuto tématu se dále věnují…


Zvyšte si kvalifikaci online z pohodlí domova

Ulcerative colitis_muž_břicho_střeva
Ulcerózní kolitida
nový kurz

Blokátory angiotenzinových receptorů (sartany)
Autoři: MUDr. Jiří Krupička, Ph.D.

Antiseptika a prevence ve stomatologii
Autoři: MUDr. Ladislav Korábek, CSc., MBA

Citikolin v neuroprotekci a neuroregeneraci: od výzkumu do klinické praxe nejen očních lékařů
Autoři: MUDr. Petr Výborný, CSc., FEBO

Zánětlivá bolest zad a axiální spondylartritida – Diagnostika a referenční strategie
Autoři: MUDr. Monika Gregová, Ph.D., MUDr. Kristýna Bubová

Všechny kurzy
Kurzy Doporučená témata Časopisy
Zapomenuté heslo

Nemáte účet?  Registrujte se

Zapomenuté heslo

Zadejte e-mailovou adresu, se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.


Nemáte účet?  Registrujte se