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The story of Beatriz is one many Mexican mothers can relate to. She lives in San Pedro Chiautzingo, a small rural community in the State of Mexico, and had not visited her health clinic for her first antenatal consultation until deep into her second trimester. She had thought that medical checkups were little more than useless and had been reluctant to undertake the five-mile uphill walk to the clinic.
At that first checkup, Beatriz was invited to a training workshop to help use her cellphone for managing aspects of her pregnancy. She attended the workshop, but not without some hesitation. A few months later one message caught her attention, because it was something that affected her own child. It read: “babies should not cry continuously for no reason”.
Despite her mother's dismissal of the advice - saying her baby was simply “a whiner” - Beatriz decided to visit her clinic again. There, the doctor noticed the baby was dehydrated, detected a respiratory infection, and decided that the baby required a special diaper to prevent hip dysplasia. Since then, Beatriz has been reading and answering almost every text, and when her sister became pregnant, she recommended her to send a message and enrol.
Introducing Prospera Digital
Beatriz is just one of more than 5,000 women who are part of Prospera Digital, a pilot randomised controlled trial. It uses behavioural sciences to test the impact of personalised and timely information delivered directly to women through free SMS messages. The logic is simple: a large number of life-threatening health complications can be prevented by giving patients access to information which is designed to elicit positive behaviour change.
Prospera Digital works through the use of RapidPro, an open source communications platform which simulates conversations by automatically sending messages to the user, then analysing the user's response and replying. In this manner, mothers receive personalised messages based on factors such as their age, their baby's birth date, the date of their next appointment, any risk factors, and their location.
Prospera Digital currently accompanies women through their pregnancy and the first two years of their babies' lives. During this period, they engage in up to 700 structured conversations that have been designed by a group of medical experts at the Mexican Ministry of Health with input from the Behavioural Insights Team.
Since its launch in December 2015, the response rates during pregnancy have been above 60%. Prospera Digital has become a trusted source of information, positioning itself as more reliable than advice provided by users' families. The preliminary evidence also shows that Prospera Digital has been able to impact directly on desired outcomes such as the overall health of mothers and babies, the mothers' levels of knowledge about their pregnancy, and their regular attendance to antenatal consultations.
To understand better why Prospera Digital has succeeded in building legitimacy and trust and is nudging women into positive behaviours, it is important listen to what the users themselves say about how they interact with the programme.
Personal and timely
Mothers tell us that a crucial component is the bespoke user experience. By personalising messages - addressing the user by name - participants feel that each message is speaking to them directly. Furthermore, users recognised that the messages are carefully timed, because they take into account the stage of their pregnancy and the age of their babies, and that they are useful in solving different problems and anticipating the changes that pregnancy and having a baby entail. It makes them feel that Prospera Digital is looking after them.
Relevant and actionable
Participants value the messages and consider the information to be clear and easy to understand. They mentioned that the project is changing the way in which they make decisions about what to do, what to eat, and how to interact with their babies.
Women also mention that the messages have delivered lessons not only on health issues but also on thinking ahead to define a financial plan to cover different expenses for the due date, such as transport and hospitalisation. “They give good advice... it helps a lot of mums who might be first-timers and don't know what to do: how to breastfeed; what to do with the belly button; about vaccinations... the information is very useful, all the messages are.”
Sociable and emotional
Users spoke constantly about small details, such as messages thanking them after a conversation is concluded. We know that the women are not only satisfied with the information they receive but have also established an emotional link with programme - because they thank the platform in return.
Based on these insights, a trial was carried out to evaluate the impact of increasing the socio-emotional content of the messages. It resulted in an 11 percent increase in response rates, proving the importance of complementing information with emotional support and positive feedback. “Yes, they even send us congratulations: ‘you are doing a good job as a mother'. And, well, sometimes these are like motivations we get from the programme, and I felt good. It's like my second husband.”
Reliable and empowering
Users of Prospera Digital were allowed to trigger alerts in case they felt they required guidance or medical assistance from a professional. Around 35 percent of those alerts were triggered by women who either made a mistake or were testing whether the tool worked, showing the importance of providing a system that is reliable, thereby increasing the user's confidence in it.
Another useful tool allows mothers to rate the quality of the medical services they receive. Their anonymous feedback is linked to an incentive scheme for medical personnel. In this way, women were able to comment on service satisfaction as well as on the fulfilment of clinical protocols (by being asked if certain procedures had been completed or offered in the consultation). This was mentioned in interviews as a leading factor enabling women to feel empowered and more in control of their own health. “[Before] I had no way to give my opinion and I didn't know what to ask the doctor during my consultations. In my last consultation I told him to check my blood pressure.”
Towards large-scale legitimacy through innovation
The Mexican government is due to launch misalud - a national programme based on Prospera Digital - by the end of 2018. Crucially, although this will roll out with a maternal health component, in the future it will also incorporate diabetes, obesity and hypertension.
This is proof that governments can boost user confidence, create stakeholder engagement, and drive political innovation through well-supported, human-centred projects designed to test, evaluate, adapt, iterate and scale. Through such services, we hope to be able to instil confidence and trust in citizens. Only in this way will governments around the world meet the needs and expectations of their citizens - through responsive public services that can truly drive change and improve people's lives.
What is legitimacy to you? Where do you see legitimacy working well? How governments work with citizens to build legitimacy is a big question for CPI.
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