Innovations in the Everyday: August Updates from Nivi
Ben on chatbots in self-care, updates from the Maternal Health Journey in Assam, Malaria Journey in Nigeria along with a deep-dive into on-ground provider engagement.
Founder’s Note
Thoughts on chatbots in self-care by Ben Bellows (Co-founder & CBO at Nivi)
I was at a workshop the other week in Dar es Salaam hosted by EngenderHealth, focusing on solutions to scale postpartum and postabortion family planning. My involvement covered financing and digital perspectives, drawing both from my past research while at the Population Council and my current role growing Nivi’s operational footprint with health system partners.
The conversations covered a lot of ground, but frequently returned to what felt like a preference for solutions centered on the health system. I was sympathetic to the conversation; supply-side interventions to boost quality and improve patient experience are familiar and serve at scale. But I kept slipping back centering on individuals in need of FP.
Mulling it over, I revisited Narasimhan, Allotey and Hardon’s 2019 paper, scanning their conceptual framing of self-care and looking for some inspired overlap with consumer digital. In their self-care model, healthcare journeys often originate in everyday life where self-care is framed by individual capacities. Self-care at home can be self-help, self-education, self-efficacy, among other capacities. However, they extend the notional space for self-care into the health system, where self-care has a “systems centered” framing that focuses on “activities that can add value in dealing with specific diseases or health issues that healthcare managers and policy makers consider important”. Activities like self-testing, self-diagnosis, and self-monitoring all involve contact with the health system. Following any health system episode, the individual continues their self-care journey by self-medicating, self-treating, or more generally, self-managing their health.
The more I thought about it, the clearer it became that consumer digital is already serving to strengthen the health system by reorienting on needs and priorities of individuals and connecting the everyday world with the health system.
Consumer-facing digital health solutions perform several core functions: educate consumers, promote health behavior change, screen for health conditions, refer to specific health products and services, solicit feedback post-visit, support self-management of treatment protocols between episodic contact with the health system.
Increasingly, chatbots have the means to do each of these core functions. As nonprofit, commercial, and public sector organizations consider chatbot solutions for their specific needs vis-à-vis targeted population segments, it is critical to consider complementarity of chatbot functions both with individuals’ self-care capacities and relevant health system services.
Maternal Health Journey in Assam, India
In April this year, we covered the launch of Maternal Health Journey in India - starting with Assam and followed it up with updates on total subscriber counts, partner facilities and staff trained in May to support the operational aspects of the MH journey. As a part of ramping up the user acquisition, along with onboarding through partner facilities, our team has also launched digital ads to expand the top of the funnel. The askNivi MH Journey has enrolled 1730+ pregnant women who are now receiving weekly messages and tips on how to manage their pregnancy. The subscribers are also receiving periodic reminders for ANC visits and upon confirmation of the same, they respond to a feedback survey on facility experience and services provided during their visit.
Through these visit reminders, askNivi has facilitated 500+ facility visits as self-reported by 297 women who’ve gone for these visits.
193 of 297 women confirmed going for at least 1 ANC visit while 64 of them confirmed visiting the facilities for 2 ANC check-ups.
15 of 297 women have confirmed having gone for 3 ANC visits while 10 women self-reported completing 4 ANC visits.
The remaining women reported going for 5th, 6th 8th and 12th visits in different numbers as seen in the graph below.
The facility experience feedback survey consists of 5 thoughtfully designed questions that are also aligned with Indian and WHO defined standards for ANC visits. These questions include feedback from pregnant women around respectful and friendly behaviour towards them by the facility staff, whether they were given explanation on why certain examinations or procedures were being conducted, did they receive the help they needed and if they were asked for consent before performing the examination or procedures. When categorized thematically, 87% of the responses indicated a positive experience and 8% indicated a slightly positive experience. 5% of the overall responses indicated a negative experience at the facility.
In addition to experience feedback, Nivi also collects a service level feedback to ensure if appropriate and timely counselling is being provided by the healthcare facility on various aspects like antimalarial medication, danger signs to watch out for, eating and exercising habits, birth plan and PPFP counselling, dangers of tobacco, alcohol and drug use etc. The survey highlighted significant areas of improvement as facilities at an aggregate level meet the expected performance on this metric 45% of the time. This is a crucial step and recognizing the emerging gaps, Nivi and our consortium partners are now working towards strengthening the experience and service level operations at the healthcare facilities by providing additional training and development programs.
We believe that through this robust feedback mechanism, not only are we facilitating improvements in the healthcare system but are also making consumers/patients aware on what to expect when they look out for high-quality ANC/PNC journey experience. Creating awareness amongst the subscribers empowers them to take charge of their health aspirations by seeking quality care when needed.
Malaria Journey updates from Nigeria
The malaria content went live on askNivi Nigeria in December and we covered the content as well as user acquisition related details in the April newsletter. We also wrote about the Malaria quiz that’s part of the content in May version of the newsletter.
Since then, 104 new users have taken the Malaria quiz taking the total users who have attempted the quiz to 304. At an overall level, the number of users answering questions correctly has declined slightly from 70% in in May to 68.5% in July.
When the group was asked about how someone gets malaria, 91% of these users gave the right answer with women being right at a rate of 90.7% and men at a rate of 92.4% - higher than the average.
When the group was asked how long it takes for the person bitten to start showing symptoms, only 41% of the users answered correctly. While only 55% of the women on the quiz got this one wrong, men answered incorrectly at a higher rate of 67%!
We also asked the users if they thought all fevers are indicative of the person having malaria and 50% of the users chose “No”, answering correctly, an improvement of 3% over the last report. Men answered correctly at a rate of 52% while women answered this correctly at a rate of 49%.
3,000+ users have interacted with the Malaria journey on askNivi Nigeria, with more than 1700 new years coming in for the Malaria Journey in since May 2023. Almost 10% (302) of the total users sought a referral for a provider facility and 12% (38) of those users reported visiting the provider. The intention of the malaria journey is to spread awareness and drive uptake of WHO Recommended rapid diagnostic tests (RDTs) so that frontline diagnosis is effective and response time to treatment is reduced.
On-ground provider engagement - process and learnings from Assam
In our previous newsletters (April & May versions), we’ve covered details on the Maternal Health Journey live on askNivi in Assam, India. Our primary goal is to create a comprehensive maternal health ecosystem where expecting mothers can access valuable information, guidance, and support through our askNivi chatbot. In addition, the askNivi marketplace enables us to partner with provider facilities and provide women with choices on where to seek care.
To achieve this, we are committed to partnering with healthcare facilities across Assam, ensuring that every expecting mother receives the care she deserves. In this article, we will delve into the intricacies of our provider engagement process, our progress so far, and our vision for the future.
Launched in April 2023, we now have 12 private facilities live on the askNivi marketplace for the Maternal Health Journey in 3 districts in Assam (Kamrul Metro, Kamrup Rural, and Nalbari) with plans to expand further. Jorhat district will potentially be the 4th district where this program will go live in the coming weeks. The coalition partners have also submitted proposals to the Government of Assam for incorporating public facilities into our focus, although approvals are still pending. We believe that this collaboration will further strengthen our mission by reaching a wider audience, given that public sector facilities account for the majority of institutional deliveries in the state.
Facility selection
Our journey began with a meticulous selection process of private facilities in our target districts. Partnering with Guwahati Obstetrics & Gynaecological Society (GOGS) was a crucial step to ensure the facilities onboarded offer the highest quality of care. The coalition’s on-ground team also visits the short-listed facilities to evaluate the suitability for incorporation into the program. We have set specific criteria to ensure that selected facilities meet the necessary standards for maternal care. These criteria include a baseline footfall per day, ANC/PNC numbers per month, and a minimum of 30 monthly deliveries. These standards are vital to ensure that the facilities can effectively cater to the needs of pregnant women.
Initial Engagement with the facility leadership
Once potential partner facilities are identified, a comprehensive proposal outlining the benefits of our partnership is shared with the facility's leadership team, which typically includes hospital administrators, medical directors, and senior healthcare professionals. The proposal describes the advantages of introducing the askNivi platform into patient consultations. These benefits include:
Shared effort allowing healthcare providers to boost their health education to pregnant women.
Enhanced patient awareness of healthy pregnancy, signs and symptoms to watch for
Ability to send reminders for the expectant mother to attend ANC / PNC services, and follow-up after each visit to gauge quality
Opportunity to improve the facility’s visibility among women and their partners seeking maternal health services
During the meetings with potential partner facilities, facility leadership are encouraged to ask questions, express any concerns, and identify ways the platform will help to improve the care they provide. Once the facility leadership is satisfied and ready to move forward, the partnership is formalized and a launch date is set. Relevant details about the facility, e.g., coordinates, hours of operation, contact information, specific maternal health services offered, are then uploaded into the askNivi marketplace. The team works on getting the required assets (IEC materials, QR code tabletop stands and vertical banners) ready to be placed at the facility.
Engagement with the Healthcare providers
The success of these efforts lies in getting the entire provider facility staff onboard. Our team conducts engagement meetings with the doctors, ANMs, GNMs, administrative staff, Ultrasound technicians and laboratorists as they are all critical touch points in a pregnant woman’s care journey. During these meetings we provide in-depth information about how askNivi can help the providers. This is one of the most important steps in the process as these providers are the people who engage with the pregnant women face-to-face.
Orientation and training providers
On the orientation day (launch date), we provide in-depth training on Information, Education, and Communication (IEC) materials that the staff can use and also provide them training on how to onboard pregnant women onto askNivi. We explain how askNivi can benefit both patients and providers. This includes helping providers understand how the chatbot can support them in counseling pregnant women and reducing the effort required to educate and inform them.
Nivi and our partner staff continue to be present at the facility during the initial stages to ensure providers become confident and self-reliant in using our platform. We provide continuous support, addressing any questions or concerns they may have so as to successfully integrate askNivi into the facility’s maternal care practices.
What’s Next?
Over the next three years, we aim to reach a total of 10 districts in Assam to ensure high quality maternal health services are accessible across a broader geography area. We also aim to onboard 200,000 pregnant women onto askNivi, whether they seek care from public or private healthcare facilities as this scale will significantly contribute to impacting maternal health outcomes in Assam. Our team will continue to train healthcare providers as the program expands, we’ve already trained 53 providers over the initial target of 30 for this year.
As we expand the services to newer facilities, we are actively working on the feedback given by both providers and patients to improve askNivi and its offerings. We continue to expand our content and include more information on factors like nutrition, exercise, smoking as our partner facilities requested in this initial phase.
Key Learnings
Our journey in Assam has provided us with invaluable insights:
Strategic Partnerships are key to success: Collaborating with organizations like GOGS and other healthcare providers has been pivotal for our success, helping us access the right facilities, talents and resources leading to a successful launch.
Comprehensive Training goes a long way: Thorough training of all healthcare staff is essential to ensure a seamless experience for both providers and patients.
User-Centric approach acts like a magnet: Our commitment to continuously improving content and addressing user feedback has been key to getting wide-acceptance for askNivi and our efforts across the facilities we work with.
Community Engagement brings it all together: Sensitizing the public about the benefits of using askNivi and the importance of scanning QR codes at the facilities has played a vital role in our success.
Our colleague, Anagha Rai is a member of the Youth Advisory Group, a Metrics for Management initiative to exchange ideas and develop innovative solutions to assess and improve the quality of SRH services for young people globally. The the Youth Advisory Group (YAG), comprised of young clinicians and SRH and human rights leaders, advocates and experts.
The YAG held its first meeting at the Women Deliver Conference 2023 in Kigali, Rwanda, a global conference that seeks to “advance gender equality and sexual and reproductive health and rights, and improve the wellbeing of girls and women.”
