2. Using mobile Phones as an Innovative Communication Platform for Family Planning Promotion m4RH: Mobile for Reproductive health Kelly L’Engle, PhD, MPH Heather Vahdat, MPH; Karah Fazekas, MPH Sex::Tech 2010, San Francisco, CA

3. Background Formative Research m4RH system Usability Testing Demonstration Monitoring & Evaluation ECINFO Challenges Overview

4. High mobile phone use in developing countries Reported popularity of texting programs and promotions Research with EC users in Ghana in 2008 and 2009 found lack of contraceptive knowledge, everyone had a mobile phone Background Photos courtesy: textually.org, thirdi.com BUT: Few family planning programs Lack of research and evaluation

5. Mobile Phone Coverage in Africa

6. Client interviews in clinics in Nairobi and Dar es Salaam, and focus group discussions in Accra (May-June 2009) Explored themes related to mobile phone use, ownership, and texting Tested the concept of providing FP information via mobile phone Tested contraceptive message content for comprehension and trust Formative Research

7. Formative Research: Text Messaging Text messaging is very common among mobile phone users. Respondents frequently participated in promotions that were advertised by text message. Respondents suggested promoting m4RH via unsolicited text messages to their mobile phones, since they pay attention to each and every message they receive. Clinics, pharmacies, and mass media also were frequently mentioned as good points for service promotion.

8. Formative Research: Sharing m4RH Participants said they would share the messages with friends and partners “I will save [the IUD messages] to show to my husband and friends” (female, 37, Tanzania) “I would tell my fellow women and my husband. I will show them the message so that they can understand” (female, 31, Tanzania). “My friends and my wife should use the service” (male, 37, Tanzania).

9. Formative Research: Content Respondents wanted to learn about contraceptive options from the text messaging service. “I will [use the service] to learn about contraceptive methods and to be able to decide which method to use when I am need of it” (female, 30, Tanzania) “I would like to learn about contraceptive methods and decide which method will be appropriate to me and my wife” (male, 37, Tanzania). Side effects were frequently mentioned as a preferred topic area. Knowing what to do if a birth control pill or an injection is missed was also mentioned as being helpful information.

10. Formative Research: Reiterating Counseling Respondents would trust contraceptive information that was received over their mobile phones, and on viewing the contraception messages said they reiterated the counseling information received from providers. “[I would trust the IUD messages] because I have been told this before by my health provider....It is like a reminder of what we have been taught before” (female, 30, Kenya). “[The implant messages] remind me of what I had been told by the provider….I would save the message so that I can keep refreshing myself when I experience any problems” (female, 42, Kenya).

11. Formative Research: m4RH Perceived as Private, Convenient, Cost-effective –“I would use the text message service because it is private and confidential.” (female, 21, Tanzania) –“[I would use the service] when at home and am relaxed. I can read and meditate more on the information.” (female, 29, Kenya) – “The service is convenient and can be accessed anytime, anywhere.” (female, 22, Tanzania) – “[I would pay to use the service] because this information is important. It may cost more when you visit clinics than if it is on your fingertips.” (female, 37, Tanzania) – “[I would pay to use the service because] it is a very good service and why use money to send messages for nonsense things instead of family planning issues.” (female, 28, Tanzania)

12. m4RH System Automated, opt-in, menu-based text messaging information service Pilots in Kenya, Tanzania, and Ghana Utilizes content from available resources (WHO, country-level FP service guidelines) Dual emphasis: 1.Providing contraceptive information via mobile phone platform 2.Evaluating how M4RH impacts contraceptive use and continuation Promotion in partner clinics (Marie Stopes, IPPF), pharmacies, and mass media

14. Sliced Bread Design provided guidance Tested in Kenya, Tanzania, Uganda Usability Testing Resulted in changes in: 1) addition of screen providing menu of all methods, 2) deletion of HELP screen, 3) some inter-system links, 4) proof of learning through using, 5) lots of small formatting changes

15. http://dev.herdingpixels.com/m4rh/ m4RH Demonstration

16. Promotion

17. Monitoring & Evaluation: System Capture

18. Which of the following best describes you? 24 and younger, Female-Reply FY 24 and younger, Male-Reply MY 25 and older, Female-Reply FO 25 and older, Male-Reply MO (168 characters) Monitoring & Evaluation: Reach

19. 4-5 Baseline questions 4-5 Follow-up questions Participation and attrition? Informed consent for research? When to “go live”? Monitoring & Evaluation: Impact

20. Research-based: barriers and intervention points based on EC research in Ghana Theory driven: locus of control; value expectancies; perceived social norms; self- efficacy, etc. Persuasive messaging: role model stories Randomized trial via mobile phone ECINFO

21. ECINFO: Randomized trial via mobile phone

22. ECINFO: Role Model Stories Hi, my name is Beth. Congratulations on using EC and taking control of your health. Since preventing pregnancy is important to you, I want to tell you about other contraception that is less expensive and longer lasting. These methods are great for single and married women. I know because my friends and I use them. To hear Sandra talk about daily birth control pills (OCPs), reply J. To learn about OCPs from Ruth and Isaac, reply R. For my experience with Depo, reply B. My friend Sandra uses OCPs and loves them. She had headaches and light nausea at first, but they went away and now her skin is clearer and her monthly bleeding is lighter and regular. When she was taking EC, her monthly bleeding was unpredictable but now it is always right on time. Sandra just bought new shoes because OCPs cost a lot less than EC – her boyfriend says the shoes are sexy! Taking a pill every day seems like a lot, but Sandra likes knowing she is protected from pregnancy all the time. Reply O for more on OCPs.

23. 1.Platform—literacy, reach, character limits, limits 2.Persuasion—behavior change on mobile phone 3.Programming and Presentation—usability, technical partner(s) 4.Evaluation—research, data collection 5.Scale up—sustainability, cost Challenges

24. USAID, PROGRESS William and Flora Hewlett Foundation Text to Change Marie Stopes International FHOK/ Planned Parenthood Kenya Sliced Bread Design NGO Community Partners—Asante Sana!