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m4RH: Reaching Young People with
Critical Sexual and Reproductive
Health Information via
Mobile Phone
Anicet Nzabonimpa, Rwanda
2014 Global m4RH Forum
Washington DC, 10 -11 December, 2014
Outline
•
•
•
•
Background and Rationale
Why and What is m4RH?
How m4RH works?
Complementarity m4RH, mUbuzima and
RapidSMS
• Implementation plan
• Conclusion
• le
Background and Rationale
In RDHS 2010:
 17% of young women and 27% of young men have had sexual
intercourse by age 18
 20.8% of women had first sexual intercourse by age 18 and nearly
3/4 of men have had sexual intercourse by age 25 (73.1 %)
 20% of young women at age 19 have already had at least 1 child
or are pregnant for the first time-RDHS 2010
In Rapid Assessment of ASRH, December 2011
 Low SRH knowledge
 Misconception on contraceptive methods
 Lack of appropriate places to seek SRH information
Why
?
 20.8% of young girls had first sexual intercourse by age 18
(RDHS 2010);
 Nearly 3/4 of men have had sexual intercourse by age 25
(73.1 %)-RDHS 2010;
 Unwanted pregnancies among young girls were due to
(1)Inadequate knowledge on SRH and appropriate places to
seek related information (2)Misconception on contraceptive
methods (Rapid Assessment of ASRH, December 2011)
 Tremendous growth in mobile phone use in Rwanda : at least
1 mobile phone per household 6.2 % in 2005/2006 and 45.2%
in 2010/2011 (Integrated Survey on Life Conditions, 2011)
 Providing SRH information via mobile technology is an
opportunity to reach the youths
 Globally USAID is promoting the use of new technologies in
health
What is
?
 SMS/USSD and internet based mobile application
designed to give young people in Rwanda access to
accurate information about sexual and reproductive
health;
 This system will be free to users and can be accessed by
anyone, not just young people;
 Messages are designed to provide information about
puberty, sex and pregnancy, HIV and other STIs, and
pregnancy prevention methods to young people ages 1024.
How does it work ?
Text “m4RH” to 6474 (to any telecom) and choose a topic:
Welcome Menu
Puberty
Sex and
Pregnancy
HIV
Sexually
Transmitted
Infections
Pregnancy
Prevention
Methods
Role Model
Stories
Youth-Friendly
Services Directory
Puberty
Sex
HIV Definition
STI Definition
Condoms
List of stories
Province
Girl's Bodies
Preventing
Pregnancy
HIV Infection
Preventing HIV/STIs
Emergency
Contraception
Automatic reception
every 3 days
District
Boy's Bodies
Abstinence
Preventing HIV/STIs
HPV Vaccine
Natural Family
Planning
Sector
Changes
Early Parenthood
Dual Protection
STI Symptoms
Daily Pills
Facility List
Sexual Feelings
Having Sex
Male Circumcision
STI Treatment
Injectable
Contraceptives
Respect
HIV and Pregnancy
Contraceptive
Implants
Post-abortion Care
HIV Testing
Intra-uterine Devices
Pregnancy
HIV Treatment
Permanent
Contraception
HIV and Traditional
Medicine
Stigma
How does m4RH technology work ?
How is m4RH different from other
existing mobile technologies?
m4RH
- SMS/USSD-based
-It
has
rich
interactive
text
content
-It is self-intuitive
-Much content can
be read from one
single screen
-Has the option of
graphic expressions
-Application can be
remotely updated
Rapid SMS
mBuzima
-SMS based
-It is not interactive, its
one way
-Very limited to 160
characters
-Complex to memorize
the codes to be used.
- No graphical
expressions
-For every change a new
card code has to be
written and trained to
all users
- It’s voice based (IVR)
- It is Interactive but not
intuitive
-There is a heavy cost
on
the
voice
transmission
- Low rate of change
due to the complex
voice generation
-Requires more network
resource
on
the
network to send voice in
comparison to SMS and
data over the internet
Browse via Smartphones for m4RH
–TESTING URL:
http://41.186.27.117/m4rh
–PRODUCTION URL:
http://m4rh.moh.gov.rw/mobile
–Android standalone:
http://41.186.27.117/m4rh.apk
Rwanda Adaptation
• Adapted content to include information about HIV, STIs,
puberty, pregnancy and pregnancy prevention
• Content testing
• Conducted 10 FGDs (Focus Group Discussions) with 74
young people ages 15-24 in urban and rural areas
• 4 FGDs with 27 parents/guardians of young people ages
10-24 in urban and rural areas
• Usability Testing
• 20 IDIs (In-Depth Interviews) with 20 young people ages
15-24
FDG Results
• m4RH was appreciated by young people and adults:
• Young people appreciated the m4RH messages
• Participants felt messages were useful, easily understood,
trustworthy
• Most participants reported intention to use m4RH when launched
• Most adults felt the information was appropriate for youth
“It gives answers
to questions we
have been
asking
ourselves.”
- 18-24 year old male in
Ngoma
“This service has
actually delayed.
The MOH should
have availed it
before.”
- Parent in Kigali
“If my boyfriend finds me
reading those messages, he
would change his mind and
would not ask me to have
sexual intercourse with him
because he would know that I
cannot accept because I have
enough information.”
- 18-24 year old female in
Ngoma
Scenario of SMS Costs per year
(Estimation-based)
Approximately 6,000,000 subscribers for all telecom companies.
Given that 40% of Rwanda's population are young people 10-24 years old, we can assume that there
are 2,400,000 young people who have access to a mobile phone. and of these 30 % (720,000) are
possible clients and may use the m4RH program.
Option 1:
1 sms = 3 Rwf (if we have same rate as for Rapid SMS and mUbuzima)
If we target 30% of 2.400.000 young people , we will have 720.000 Beneficiaries
3 sms sessions/day/person x 720.000 people x 366 days/year = 790,560,000 sms
790,560,000 sms x 3 Rwf = 2.371.680.000 Rwf ($3.753.874)
Note: After Year 1, users will cover the sms costs and only marketing and maintenance costs
Option 2:
1 sms = 1 Rwf (if MoH negociate rate since the target is bigger than for the 2 other products)
3 sms sessions/day/person x 720.000 people x 366 days/year = 790,560,000 sms
790,560,000 sms x 1 Rwf = 790,560,000 ($1.179.940)
Note: After Year 1, users will cover the sms costs and only marketing and maintenance costs
Normal rate for sms is 15 Rwf
Conclusion
 m4RH program in Rwanda is be well received
 The results of the previous studies helped to guide the
adaptations of m4RH in other settings and to include more
comprehensive SRH information that is tailored for young
people.
THANKS
The Mobile Generation:
Designing Mobile for Reproductive Health
Global mHealth Forum
December 10-11, 2014, Washington DC
Kelly L’Engle, PhD MPH
The Mobile Generation
In the last five years, the number of
mobile phone subscribers worldwide has
doubled and is approaching 7 billion.
Nearly one third of mobile phone
subscribers are under the age of 30.
Worldwide, more than 200,000 text
messages are sent every second.
Using Mobile Phones for ASRH
• Young people are responsive to and excited about using new
technologies
• Mobile phones
– Are relatively inexpensive, portable and accessible
– Offer perceived privacy compared with face-to-face meetings
with health care providers and counselors
– Are a low cost method to reach millions with critical SRH
information
– Provide an exciting platform for BCC programming
• Many mHealth programs
m4RH
Basic FP
Messages
Expanded
FP
Messages
SRH
Youth
Messages
Weekly
Messages
Role
Model
Stories
Clinic
Locator
Systematic Content Development Process
1. Concept Testing with targetin focus groups and interviews
2. Message Development in 160 characters; based on literature and evidence,
global and country-level guidelines, translated if necessary
3. Message Approval by MOH and global and local FP experts
4. Message Testing with health clinic clients
5. Usability Testing to refine system interaction and navigation
EXAMPLE MESSAGE: Condoms (male or female) are the only method that protect against
both pregnancy and STIs, including HIV. Even if you are using another form of contraception
to prevent pregnancy you should still use a condom to protect yourself from STIs
Evolution
2008-2009
2010-2011
2012
2013
2014
2015
•FHI 360 developed
m4RH through
USAID’s PROGRESS
(Program Research
for Strengthening
Services) project
•PROGRESS piloted
m4RH in Kenya and
Tanzania
•m4RH plus
launched in
Tanzania
•m4RH adapted for
youth in Rwanda
•m4RH youth
adaptation in
Tanzania underway
•m4RH adaptation
in Uganda to begin
Spring
Chat Salud
mCenas
ARMADILLO
Data on Age, Gender, and Marital
Status
Gender (n=32,472)
Age (n=32,246)
<19
20-24
15%
25-29
female
30+
Marital Status (n=32,472)
male
married
single
22%
40%
44%
22%
60%
41%
56%
Data on Rural and Urban Reach
• N=25,000 (42% response)
• April-September 2012
• 127/129 districts in
Tanzania reached by m4RH
m4RH Kenya RCT Users at Baseline
• Young adults
– Average age is 25 at baseline
– (under 18 were excluded
from study)
• Large percentage of males
– 68.4% women, 31.6% men
Thank you!
[email protected]
11 December, 2014
Global mHealth Forum
Adolescent/Youth Reproductive
Mobile Access and Delivery
Initiative for Love and Life
Outcomes (ARMADILLO) Study
Lianne Gonsalves, MSPH
Consultant, Department of Reproductive Health and Research, WHO
25
Rationale: why mHealth and
ASRH


WHO Department of
Reproductive Health and
Research leads and coordinates
independent research,
particularly on sensitive and/or
understudied areas
Extensive portfolios in mHealth
and innovations for RMNCH,
adolescent sexual and
reproductive health (ASRH)

ASRH: guidelines and strategies for
improving youth-friendly health
services; case studies on ASRH
education implementation
Marrying two understudied areas
Flagship issue for 2014
Exploring innovative ways for reaching
adolescents/youth on SRH issues outside of facilities
Reviewing the evidence
Department supported FHI360 to conduct systematic
review assessing the evidence (and quality of evidence) of
mHealth strategies for adolescents and youth
Findings:
• ASRH projects show promise in addressing barriers to
knowledge, behaviour, and access
• SMS as channel for delivery key in LMICs, popular in
provision of general SRH information
• Current lack of gradable evidence coming from LMICs,
despite increasing number of projects
ENTER THE ARMADILLO (STUDY)
Overview: the Intervention
• Background: Partnership between WHO, FHI360, country
research partners
– SMS-based, interactive, and menu-driven service
– Reflective of national and global guidance with active
community participation in development
– On-demand, zero-rated service
• Will provide SRH information across variety of domains to
youth (on-demand)
– Incorporate role model studies (pushed to phones)
• Strong emphasis on research: process documentation and
evaluation
– Using a channel for delivery that is (1) popular and (2) widely
available
Site information
Mtwapa, Kenya
• Peri-urban setting outside
of Mombasa
• Population ~63,000
• Unique mobile subscriber
penetration of 31% (Kenya)
• Legal framework supporting
young person access to
reproductive health
information and services
Cebu City, Philippines
• Urban setting, capital of
Cebu province
• Population ~860,000
• Unique subscriber mobile
penetration rate of 49%
(Philippines)
• Complex and conservative
legal framework regarding
A/YSRH, evolving slowly
• University of San Carlos,
Office of Population Studies
Content development
Developing ARMADILLO content (2-3 months)
Objective: Develop ARMADILLO content, ensuring it is
reflective of youth needs, national guidelines and priorities
in A/YSRH.
• Message Development Committees assemble youth,
A/YSRH providers, and key stakeholders in each site,
prioritize and tentatively finalize draft content
• Ensures key youth-driven reproductive health messages
are included and conveyed in an appropriate manner
Ready for testing and refinement…
Structuring study focus…
…by answering three questions
1. Is this something youth want?
2. What is the impact?
3. Can we reach youth?
–
Can we reach all youth?
1. Formative stage
2. Impact RCT
3. Coverage Study ARMADILLO rollout
1. Formative stage
The formative stage
1. IS THIS SOMETHING YOUTH WANT?
1. Formative stage
Formative research: Phase I
Content Testing (2 months)
Objective: Test and refine ARMADILLO content to ensure it is
appropriate, appealing, and engaging for youth users
• Methods: Focus Group Discussions with youth, parents/caregivers
• Study Population: Youth aged 15-24 who are regular mobile phone
users with adequate text message literacy, parents of young people
1. Formative stage
Formative research: Phase I
Key Outputs for Phase 1:
ARMADILLO:
• ARMADILLO messages and promotional material has been
modified, reviewed and finalized by youth
Understanding local context for youth and mobile phones:
• Mobile phone use/sharing habits
• Any privacy concerns
• Appeal of delivery of SRH content on mobile device
• Reliability, ‘shareability’, ‘recommendability’ of messages
1. Formative stage
Formative
research:
Phase
II
Phase II: Peer Piloting (3 months)
Objective: Determine whether ARMADILLO is usable by
youth, finalize platform
• Methods: Pre-Post test, peer piloting, in-depth interviews
• Study Population: Youth aged 15-24 who are regular mobile
phone users with adequate text message “literacy”
1. Formative stage
Formative research: Phase II
Phase II learnings…
ARMADILLO usability:
• Ease accessing/navigating the system
• Technical appropriateness of message construction/content
• Appeal of system access and message sharing
ARMADILLO study content:
• Finalized tools to be used to assess impact in later study stage
ARMADILLO SRH content:
• Popular domains of content
ARMADILLO platform is finalized…
2. Impact RCT
The impact assessment
WHAT IS THE IMPACT?
2. Impact RCT
What is ARMADILLO’s impact?
Outcomes
Note: behaviour will be measured but not as a key outcome
1. Technical knowledge
•
Comprehension
2. Norms around SRH information and services
•
•
•
Acceptability of seeking/using SRH information, commodities,
and services
Acceptability of other youth seeking/using SRH information,
commodities, and services
Acceptability of others thinking that youth (participant)
seeks/uses SRH information, commodities, and services
3. ‘Knowledge for action’ (self-efficacy)
•
For seeking services, communicating, etc
2. Impact RCT
Methods
• Proposed RCT
• Eligibility criteria:
–
–
–
–
–
15-24 years old
Regular access to a mobile phone
Regular use of SMS
text message literacy
able to provide informed consent
• Diversity in recruitment sites – to get
representation from across the relevant
population
2. Impact RCT
RCT Implementation
• Those randomized into ‘treatment’ are given
information on accessing ARMADILLO system
– Reminders to interact with system pushed out
periodically (e.g. in the example of role model
stories)
• Control group receive non-SRH content
pushed to phones at same frequency of
ARMADILLO ‘reminders’
• In-person follow-up 6-8 weeks
3. Coverage study
The coverage assessment
CAN WE REACH YOUTH?
CAN WE REACH ALL YOUTH?
3. Coverage study
Methods
Study Design
• Proposed mixed methods,
pre-post measurements
surrounding ARMADILLO
launch
– Intense promotion in
‘ARMADILLO’ area, close
watch on promotion
strategies
Participants: 3 categories
Why were they not reached?
All youth
Aware of ARMADILLO
Why did they not access the system?
ARMADILLO users
3. Coverage study
Who do we reach with
ARMADILLO?
• What kinds of youth are we reaching (or not
reaching)?
• What is youth awareness of the system?
– Perceived purpose of and trust of ARMADILLO system
and information
• How do youth engage with the system?*
– Interactivity, liking, comprehension
– Message sharing
* Great potential to leverage the phone for data
collection
Timeline
Formative stage – 11 months
Impact RCT – 5 months
Coverage Study - ARMADILLO rollout
Jan 2015
• Total duration: approx. 3 years
• Stage implementation reflective of scaling with
evidence
– Get evidence that it “works” (impact), then assess
coverage (reach)
– Reduce potential for contamination in RCT
• Cost-effectiveness data will be also collected and
THANK YOU!
Youth, Sex, Stories, and Mobile Phones
mCenas! Engaging Young People in Mozambique with SMS-based SRH Stories
Mahomed Riaz Mobaracaly, MD
Programs Director
Maputo, Mozambique
Extending Service Delivery/Family
Planning Initiative PROJECT
• Goal: To integrate
contraception
services into existing
primary health care
and HIV services to
decrease the unmet
need for
contraception in
Mozambique and
contribute to the
reduction of the high
rates of maternal
and child mortality
FP
Integration
Adolescent
& Youth
Results
Community
Pre-Service
WHY mCENAS! in MOZAMBIQUE?
•
Contraception rates have not risen during last 10 years
•
Only 8% of women between 15 and 19 years old uses a
modern contraceptive method (15% of the women
between 20 to 24 years old)1
•
At age 15, 5% of girls have given birth to a child and by
the age of 19, 63% have given birth to a child
•
In Mozambique in 2012, 35 per 100 inhabitants had a
mobile cellular subscription2 and 33% of inhabitants
had a mobile device3
•
1) DHS, 2011; 2) ITU, 2012; 3) GSMA, Deloitte 2012
Design of
mCenas!
Three components
1. Story using barriers and
facilitators
2. Informational messages
on contraceptive
methods
3. Interactive, frequently
asked questions menu on
range of sexual health
and reproductive health
topics
Participatory and iterative Message development
process
• The Pathways to Change game was used to gather
information from youth about barriers and facilitators
of contraceptive use
• Follow-up focus groups, revisions, and pre-testing of all
content, supplemented by field staff expertise
• Two stories developed for people with and without
children, written by Mozambican script writer, using
local texting slang
• Contraceptive method messages adapted from m4RH
• Sexuality FAQs developed by asking young people to
sort initial list in order of interest and add topics
mcenas! Message delivery System
and timeline
Month 1
Month 2
Month 3
Story messages sent 3x a week for 8 weeks (1 story for
youth with children; 1 story for youth without children)
Contraceptive method
information messages
sent to users 3x a week
for 4 weeks
Contraceptive method information menu available
SRH FAQ menu available
Use of
mCenas!
TOTAL ENROLLMENT IN mCENAS!
• Enrollmment period: September 2013 until
February 2014
• 2,005 young people (aged 15-24) were
Age
Gender
enrolled in mCenas! by peer educators (no
15-17
self-enrollment)
Women
year olds
54%
46%
18-24
year olds
Parenting Status
33%
67%
Have a
child
Do not
have any
children
43%
57%
Men
Information requests: Sexuality
FAQ and Contraceptive Methods
• Sexuality FAQ request: 10,451
– Three most commonly requested topics:
• Am I ready for sex?
• Masturbation
• Sexual pleasure
• Requests for info on contraceptive methods:
6,887
– Three most commonly requested methods (for
info)
• Injectables
• IUDs
Engagement with the system: non-conforming
responses
• We have received over 8,641 incoming
messages that aren’t recognized by the
system
• Messages suggest audience engagement with
stories and desire for interactivity
• About half are free form text messages in
these categories:
– Love and relationship questions
– SRH questions
– Comments on stories
My dear, every man says he will withdraw his penis
and ejaculate outside, even my man. If he doesn’t
agree to use condoms, don’t go to bed with him. Be
a real woman. Value yourself and don’t wait for
someone else to value you...
kerida todo o homem diz k vai tirar o penis pa
ejacular fora ate o meu.evita meu anjo.se ele nao
aceita com camisinha simplesmente nao aceita ir a
cama com ele.seja mais mulher,valorize e nao xpere
k ninguem t valorize antes de ti linda.o z? ta muito
aprexado eu axo.converse cm ele e faxa o perceber
k sem a camisinha nao da.pense bem ta.
E2A Project Assessment of
mCenas!
Select Preliminary Findings
E2A Assessment of mCENAS!
Objective: generate evidence to determine whether sending
SMS with contraception information to youth aged 18-24 years is
acceptable, and will improve knowledge, attitudes, self-efficacy
and intention regarding contraception use.
• When: Baseline (Jan-Feb, 2014) and endline
(June-July, 2014)
• Where: Matola district of Maputo Province
and Inhambane City district of Inhambane
Province
• Who: 895 participants recruited at baseline;
504 of them reported for interviews at
Characteristics of Study
Respondents
Respondent Characteristics :
Males (%)
Females (%)
20-24 years
60.3
52.5
In school
57.6
62.8
Married/cohabiting with a partner
24.6
24.7
With one or more children
51.0
48.6
From Matola (mostly urban)
67.7
67.6
Who depend solely on parents/relatives
for livelihood
30.7
68.8
Total (number)
257
247
Improvements in Knowledge
• Knowledge measured using set of questions
about safety, ease of use, when to use, and
effectiveness of each method
• For each method, knowledge classified as
none, low, medium, or high
• Overall trend: increase in number of methods
for which respondents had medium or high
knowledge
Increased Knowledge of a Range of
methods:
Percentage of men with medium or high knowledge
100
90
80
70
60
Baseline
50
Endline
40
30
20
10
0
None
One Method Two Methods Three Methods Four Methods Five Methods
Six Methods
Increased Knowledge of a Range of
methods:
Percentage of women with medium or high knowledge
100
90
80
70
60
Baseline
50
Endline
40
30
20
10
0
None
One Method
Two Methods
Three Methods
Four Methods
Five Methods Six or More Methods
Other trends in use and intention
to use
• Relatively high rates of contraception use at
baseline may be due to projects previous work
in YFS and peer education
• Observable shifts in preferred method among
those intending to continue/start a method,
most notably an increase in preference for
implants, among men and women, with and
without children.
• Indication that when young people are
presented with information on a complete
Lessons from
Program Design
and
Implementation
Lessons Learned
• Use of a local script writer, story-based
messages, text message slang, and
participatory design process with youth was
essential.
• Young people are eager for a higher degree of
interactivity with the system, and expect
personal responses to their SMS.
• Menu system is challenging to use (both FAQ
and contraceptive method messages).
MORE Lessons Learned
• Simplify registration: Have fewer registration
questions and consider self-enrollment that is
not dependent on peer educators.
• Youth cell phone numbers change often (SIM
expires, number changes, phone lost or
stolen, SIM given to someone else).
• Mobile networks have frequent outages in
Mozambique resulting in challenges for
recruitment and potential missed/skipped
messages.
For more information contact :
Riaz Mobaracaly
[email protected]
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