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! klengle@fhi360.org 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 MMobaracaly@pathfinder.org twitter.com/PathfinderInt facebook.com/PathfinderInternational Thank you! Youtube/user/PathfinderInt