Half the Sky Movement Multimedia Communication Initiative: An Evaluation of the 9 Minutes Mobile Game and Video

"Today, little data exist on the effectiveness of mobile games as channels for social and behavior change communication - and in particular on their effectiveness in addressing health issues in developing countries."

This study evaluates one component of Half the Sky Movement, a global multi-media, multi-partner initiative using handheld mobile games as a tool to promote healthy behaviours in India and East Africa on topics such as maternal health, child health, and girls' education and empowerment. One of these games simulates the experience of 9 months of pregnancy in 9 minutes, presenting players with a series of physical, medical, and social choices in a race against the clock. Players race to collect icons that represent healthy pregnancy choices for a particular month of pregnancy and to avoid icons representing the unhealthy choices. Accompanying the mobile game is a short video that also highlights key actions ("pregnancy do's") that women and their families can take to ensure a happy pregnancy and birth. A brief facilitated discussion guide, related to the products, for use with small groups was also developed as part of the larger media package.

This study examines changes in knowledge, attitudes, and behavioural intentions related to pregnancy and delivery after Indian participants played the 9-Minutes game several times; some participants also watched the complementary educational video. The study utilised a mixed-methods design with quantitative pre-/post-tests combined with qualitative focus group discussions (FGDs). All participants were exposed to the 9-Minutes intervention package in the context of the evaluation, as distribution of the products had not yet begun in India. The study's intended populations included married women (aged 18-44) who were pregnant or intended to become pregnant within the next year and husbands of women of reproductive age who were pregnant or intended to conceive within the next year. Group A participants were exposed only to the 9-Minutes game, while Group B participants played the game, watched the video, and participated in a brief facilitated small group discussion (intervention package).

Researchers found that exposure to the 9-Minutes intervention package resulted in measurable shifts in knowledge, attitudes, and behavioural intentions toward promoted safe pregnancy and delivery actions. It also found that the multimedia products were considered acceptable and well-liked among study participants. Participants recalled a range of promoted messages and actions gleaned as a result of their exposure to the intervention package and expressed desire to share what they had learned with others. Significant increases in knowledge-related items were found - most notably around correct knowledge of the number of optimal antenatal care (ANC) visits and key pregnancy "dos" and "don'ts". The findings also revealed significant shifts in key outcomes correlated with behaviour change:

• Increased perceptions of susceptibility to and severity of pregnancy/delivery complications in the absence of appropriate ANC or institutional delivery;
• Increased perceptions of benefits;
• Decreased perceptions of barriers;
• Increased perceptions of supportive community norms around pregnancy/delivery and gender;
• Increased self-efficacy; and
• Increased intentions to act related to the 9-Minutes topics.

Overall, the 9-Minutes evaluation "demonstrated post-intervention increases across outcomes consistent with behavioral theory, suggesting that the intervention package may be associated with an increased likelihood of behavior change and may be effective in driving demand for promoted pre and postnatal services as well as contributing to efforts aimed at driving normative change. It is recommended that distribution of these products be paired with ongoing evaluation in order to gauge their effectiveness in 'real world' settings. As the use of mobile games and new media become more widespread as social and behavior change communication tools, it is important to caution overemphasis of these communication channels in the absence of additional reinforcing communication channels, including interpersonal communication as SBCC [social and behaviour change communication] aims to have synergistic effects across multiple strategies and channels to generate a supportive environment for change. It will also be important to look at the impact of these types of products across demographic groups and health and development issues."

CMS Communication, a team of CMS (Centre for Media Studies) conducted this research in India. The project is supported by the United States Agency for International Development (USAID). Show of Force, Games for Change, and Fenton Communications were partners in developing the products under this initiative.

9 Minutes is part of a suite of mobile games - including Worm Attack! (deworming awareness) and Family Values (highlighting the place and value of girls in their family) - designed for underserved communities in India, Kenya, and Tanzania. The 3 games, developed and distributed together with Mudlark (United Kingdom) and E-Line Media (United States), were finalists in the 2013 INDEX: Design to Improve Life Awards.