MoMoMa 2: mHealth_Pathfinder
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Pathfinder presented their mHealth project in Mozambique at Mobile Monday Maputo's second event.
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MoMoMa 2: mHealth_Pathfinder
- 1. mCenas Engaging Young People in Mozambique with SMS-based SRH Stories July 07, 2014
- 2. ESD/FPI 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 • Results: – Integration of the delivery of contraception counseling and services into primary health care and HIV/AIDS services. – Increased availability and demand for both contraception and HIV/STI services for students, faculty, and staff in pre-service training institutions. – Community capacity to increase access to and quality of contraception services strengthened. – Youth have greater access to contraception, reproductive health, and HIV services through youth-friendly health centers.
- 3. ESD/FPI PROJECT OVERVIEW CABO DELGADO (51 HF + 6 YFS) • Namuno • Pemba • Chiúre • Montepuez • Balama • Ancuabe INHAMBANE (30 HF + 3 YFS) • Zavala • Massinga • Inhambane GAZA (64 HF and 3 YFS) • Cidade de Xai-Xai • Distrito de Xai-Xai • Macia • Chókwe • Chibuto • Manjacaze MAPUTO PROVINCE (13 HF + 4 YFS) • Matola The project supports 157 health facilities (HF) and 16 sites with youth-friendly services (YFS). Project dates: July 15, 2010 – July 14, 2014 Funding source: USAID
- 4. • In response to the growing use of mobile phones in Mozambique, Pathfinder opted to develop a comprehensive text message based program that targets youth (15-24; with and without children) with educational messages. • The goal of the project is to engage youth in a SMS-based role model story and informational message system that will increase knowledge about contraceptive methods, dispel common myths around contraception, and address common barriers youth face regarding use of contraception. WHY mCENAS! in MOZAMBIQUE?
- 6. OVERALL DESIGN OF mCENAS! • We wanted to provide, not only information to youth, but also try to foster reflection and strategies to overcome barriers and maximize facilitators for use of contraceptive and other SRH services. • We started with one of the cornerstones of Pathfinder’s behavior change approach, which is the use of narrative (or stories) in order to present information in a format that is able to contextualize and highlight multiple dimensions of behavior. • FPI is focused on contraception, but we wanted also to provided young people with some basic information on the sexual health topics that were most important to them. • An interactive FAQ menu system was created.
- 7. THREE COMPONENTS 1. Story using barriers and facilitators 2. Informational messages on contraceptive methods 3. Interactive frequently asked questions menu on range sexual health and reproductive health topics
- 9. QUALITATIVE DATA FOR STORY DEVELOPMENT • The Pathways to Change game was used to gather information about barriers and facilitators of contraceptive use and to generate initial story ideas. • 14 sessions were conducted with demographic subcategories: – girls/boys – younger/older – in/out of school – with/without children – 2 locations • Important differences between parenting/non-parenting, so we created 2 different stories.
- 10. STORY WRITING PROCESS • Involvement of experienced Mozambican script-writing consultant was key • Prioritization of key behavioral influences • Iterative process drawing on field staff experience, follow-up focus groups, revisions, and pre-testing • Story line divided into 24 chapters ‒ Each chapter shoe-horned into three 160 character (Portuguese) messages ‒ 8 weeks with 3 chapters per week • First person narrative style chosen • Use of texting slang/abbreviations essential
- 11. COORDINATION WITH ALO VIDA HOTLINE • Existing HIV telephone hotline • Pathfinder provided additional SRH training to operators • mCenas! users encouraged to call • From January - June 2014: 707 mCenas! referred calls
- 12. Month 1 Month 2 Month 3 SRH FAQ menu available Story messages sent 3x a week for 8 weeks (1 story for youth with children; 1 story for youth without children) Contraceptive method information menu available Contraceptive method information messages sent to users 3x a week for 4 weeks mCENAS! MESSAGE DELIVERY TIMELINE
- 14. ENROLLMENT AND RECRUITMENT • Training of 20 peer educators from two youth community- based organizations of Matola in Inhambane on how to register • Outreach activities held at secondary schools and in communities: – door to door campaign – health fairs – community events
- 15. Eligibility to enroll in mCenas!: • Between 15 – 24 years of age • Have a cellphone of their own • Minimum ability to use text SMS ENROLLING IN mCENAS!
- 17. DEVELOPMENT PROCESS • Partnership with Dimagi, Inc – used CommConnect platform • Registration and interaction done via keywords and numbers (ping-pong menu system) • Narrative and information messages timed for delivery • Used SISLOG Aggregator and dedicated short code obtained for MCEL, Vodacom, and Movitel • SMS messages were free for clients (except Movitel)
- 19. • Enrollmment period: September 2013 until February 2014 • We have 2,005 young people enrolled in mCenas! TOTAL ENROLLMENT IN mCENAS! 57% 43% Gender Women Men 46%54% Age 15-17 year olds 18-24 year olds 33% 67% Parenting Status Have a child Do not have any children
- 20. INFORMATION REQUESTS: SEXUALITY FAQ MESSAGES Menu Messages Number of Requests (N=10,451) Am I ready for sex? 14.1% (1,474) Masturbation 9.1% (955) Sexual pleasure 8.9% (931) Can I be pregnant? 8.7% (907) Can I have an STI or HIV? 8.4% (882) Am I ready to have a child? 8.4% (880) Menstruation 7.8% (813) Sex and violence 6.6% (689) Personal hygiene 6.5% (679) Post-abortion 5.7% (594) Circumcision 5.4% (561) Sex post-partum 5.3% (557) HIV and pregnancy 5.1% (529)
- 21. INFORMATION REQUESTS: CONTRACEPTIVE METHODS Contraceptive Method Number of Requests (N=6,887) Injectables 18.7% (1,288) IUD 12.7% (875) Implants 12.0% (826) Pill 11.2% (770) Male condoms 10.9% (754) Amenorrhea by lactation 9.9% (679) Emergency contraception 9.4% (645) Female condoms 8.8% (609) Where to go for FP 6.4% (441)
- 22. 73% 21% 6% 0% 10% 20% 30% 40% 50% 60% 70% 80% Interesting Just ok Not interesting mCenas! SMS Question: “How do you like the story?” sent mid-intervention (N=513)
- 23. • Only 32 users have opted out (1.6% of users) • Most commonly cited reason for opting out – Too many messages (15 users) OPTING OUT OF mCENAS!
- 24. Lessons Learned
- 25. LESSONS LEARNED: MESSAGE AND SYSTEM DESIGN • 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 in the system • Menu system challenging to use (both FAQ and contraceptive method messages) • Unable to track actual receipt of messages, hence engagement questions asked
- 26. LESSONS LEARNED: ENROLLMENT AND RETENTION • Need differential strategies to recruit youth with children • Simplify registration: Have fewer registration questions and consider how to do registration without big events/mass enrollment • 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: – Challenge for recruitment – Also potential challenge for missed or skipped messages (more problematic with story-based messages)
- 27. NEXT STEPS • Prepare final program report with analysis • Refine content and strategy for potential continuation and expansion in Mozambique • Incorporate lessons learned into other global SMS programs • Use forthcoming E2A research study findings to make changes to mCenas! as needed
Notas do Editor
- Mention here that USAID-funded project
- YFS are also being important places where integration is happening as we are counseling and testing for HIV and also offering FP for youth. Integration into PHC in all 157 HF, into HIV Services 22 HF.
- So we landed on these three components for the system and proceeded with the design of the content.
- The Pathways to Change tool (http://www.pathfinder.org/publications-tools/pdfs/Pathways-to-Change-Moderators-Handbook.pdf) was used to gather information from the target population about the barriers to and facilitators of contraceptive use, and to generate initial story ideas. Fourteen sessions were conducted with demographic subcategories in order to detect differences in the perceptions and experiences by place of residence, age, gender, educational status, and whether or not they had children. One additional follow-up focus group was conducted with a mixed group. Example of differences: -Influence/challenges of the in-laws (sogras) who value fertility and a daughter-in-law who produces many children quickly and uphold traditions/beliefs (like the point above) -Belief that women with a new baby shouldn’t have sex at all and therefore shouldn’t seek contraception. This is linked with belief that semen damages breast milk. It seems fairly acceptable or perhaps not acceptable but understood if a man pursues another partner during this time. There is not consistency in terms of time that they should go without sex (Ranges from 6 months in Matola to 18 months mentioned in Inhambane). -and for non parenting: Scared parents will find out they are sexually active if they find out about contraception use
- An experienced Mozambican script-writing consultant was involved and she, together when the visiting Pathfinder HQ advisor went through the lists and compared frequency of barrier/facilitator mention to determine the top 2-3 barriers and facilitators that we could build a story around. The script-writer and the HQ advisor, with input from local staff with community experience, brainstormed story lines around the key barriers and facilitators prioritized previously. This included development of the story’s “world” (which we decided would be the same for both stories) as well as the development of the two main female and male characters. It should be noted that we did extensive checking to define a world that would be relevant to both rural and peri-urban youth. The stories were read to a small group of staff (4) for feedback at the end of the day. This generated excellent discussion and a number of good ideas which were incorporated into the stories. The script-writer worked to develop the full story lines, broken into 24 “chapters” each. These were again reviewed and revised by local staff and an HQ behavior change advisor. (Note from this point on, all content development occurred in Portuguese) Each chapter was then put into SMS form (three 160 character messages per chapter) utilizing local youth texting abbreviations and expressions The 2 stories in SMS format were pre-tested with the corresponding groups for comprehensibility in both provinces.
- CAMILLE
- **TRANSITION TO ANA
- The sexuality topic which got the most hits was “Am I ready for sex?” (which might be because it was the first menu item), followed by masturbation & sexual pleasure
- Injectable contraception was the method about which users most often requested additional information from the menu, followed by IUD and implants.
- **TRANSITION TO CALLIE
- Need differential strategies to recruit youth with children (limited mobility, opportunity costs of leaving home) Be cognizant of political context (confusion with enrollment for military) Have fewer registration questions and consider how to do registration without big events/mass enrollment (which overwhelm slow networks) Cell phone numbers, particularly for youth, change often (SIM expires, number changes, phone lost or stolen, SIM given to someone else) Mobile networks have frequent outages in Mozambique: Challenge for recruitment Also potential challenge for missed or skipped messages, which is more problematic in the context of story-based messages.