"Many demand generation programs, programs that increase awareness of and demand for health products or services among an intended audience, address the information needs of clients prior to visiting a provider and encourage them to seek out FP counseling. But those programs usually fall short in preparing the clients to be active and engaged communicators during the counseling itself."
This report presents findings from a cluster-randomised control trial designed to assess the effects of a digital health tool among women of reproductive age in Kaduna city, Nigeria. The Health Communication Capacity Collaborative (HC3) family planning team developed the tool for implementing partners to use to increase the number of family planning (FP) clients who are informed, empowered, and confident - in other words, “smart clients” - who are able to engage with providers and talk about their FP needs. Because women and men are often not equipped with the skills they need to communicate effectively about personal and sensitive subjects - such as sex, fertility desires, and using FP methods (that may go against cultural taboos) - this project sought to address the information needs of clients prior to visiting a provider and most of all to prepare the clients to be active and engaged communicators during the counseling itself.
The digital health tool, named Beta Life in Nigeria, was designed to reach clients directly through mobile phones. The tool consists of prerecorded interactive voice response (IVR) calls that include a variety of segments: an introduction, a serial drama, a friend-to-friend chat, a personal story, and a sample dialogue. Three short quiz calls ask users a few brief questions to reinforce key messages, evaluate user understanding of content, and encourage user engagement. In addition, users receive a short message service (SMS) reminder about the key message from each call. The digital health tool audio recordings and SMS were provided in Hausa for this study. As explained in the report, “[T]he tool is based upon Social Learning Theory, which posits that people learn from each other through observation, imitation and modeling. The 'smart client' tool therefore uses fictional role models, who demonstrate the desired behaviors and behavior change process in a drama format, as well as personal stories and examples of “smart client” dialogues. This allows the intended audience to observe an action, understand its consequences and become motivated to repeat and adopt it. While drama is a common approach used in behavior change communication, it is usually delivered via television, radio or community theatre. This digital health tool is exploring how drama can be adapted to mobile phones via IVR, using shorter and simpler story lines and episodes while maintaining the fictional drama style.”
To assess the effectiveness of the tool, HC3 undertook research that was designed to:
- Explore user acceptability and comprehension of the content and key messages;
- Explore user experiences using and interacting with the technology; and
- Assess the link between exposure to the digital health tool and contraceptive-related ideation, intentions, and behaviours.
A quasi-experimental, pre-post design with intervention and control groups was used for this study. Trained field agents went door to door in selected local government areas (LGAs) to recruit women aged 18 to 35 years, who were never-users or lapsed users of modern contraceptive methods, into either the intervention or control group. Consenting participants in the intervention group were registered to receive the Beta Life calls. The control arm did not receive the Beta Life intervention but received two calls on their mobile phone: one at the beginning of the study for the pre-intervention survey and one six weeks later for the post-intervention survey. Data from the platform-facilitated pre-intervention and post-intervention survey calls, as well as user analytics collected by the IVR platform, were combined with pre-study and post-study data to conduct the analyses presented in this report.
The ideational and behavioural outcomes that were assessed include the following:
- Ever given thought to the number of children desired
- Level of confidence in one’s ability to discuss one’s concerns about contraceptives with a provider
- Discussion of desired family size with one’s spouse in past six months
- Discussion of contraceptive methods with one’s spouse in past six months
- Rejection of the misconception that contraceptives can harm the womb
- Currently using any contraceptive method (i.e., traditional or modern)
- Currently using a modern contraceptive method
In spite of the challenges related to participants’ attrition (in both control and intervention groups but higher in the intervention group), the women exposed to the tool had very positive opinions about it. "The majority was of the view that the tool was very easy to use and most particularly liked the drama series and the chats and questions by the hosts. More important, the tool appeared to have positively influenced those who were exposed to it." The results are described in detail in the report, however, in brief, the report summarises the findings as follows: “All the ideational and behavioral indicators assessed increased significantly in the intervention group while declining or remaining unchanged in the control group. Results of the per protocol DID [difference-in-differences] analyses revealed that the tool led to an increase of 61.5 percentage points in perceived self-efficacy to discuss concerns about contraceptives with a provider, 43.3 percentage points in consideration for desired family size and 41.2 percentage points in spousal communication about family size. Similarly, the per protocol analysis showed that the tool also increased spousal communication about contraception by 22.7 percentage points, rejection of misconception about the effect of contraceptives on the womb by 48.5 percentage points and use of modern methods by 34.8 percentage points. Findings from the intention-to-treat analysis largely echo the positive results from the per protocol analysis, although, as expected, the effects were generally smaller. The significant results from the intention-to-treat analysis strengthens HC3’s confidence in the claim that the tool has been effective in improving ideational characteristics related to contraception and in increasing contraceptive use.”
In view of the findings of this study, the report makes a series of recommendations. To mention just two here - as the research had found that the tool requires numeracy skills and an appreciable level of comfort using the telephone keypad, the report recommends that efforts be made to make the tool more accessible by, for example, eliminating the need for listeners’ input during the calls. In addition, in order to reduce the rate of attrition, the programme should explore reducing the number of programme calls. One option might be to reduce the number of drama episodes without loss of relevant content. Furthermore, implementers of future adaptations of the tool could consider ways to reduce the length of each call.
The report also cites a number of lessons learned from this study, which fall into two categories: tool development and implementation; and evaluation of effects. In relation to tool development and implementation, one lesson learned relates to the many challenges still faced by mobile-phone-based interventions due to the everyday challenges faced by many owners and users of mobile phones. Commonly reported issues included sharing a phone with others, a lack of electricity (making it impossible to keep the phone charged), phones being lost or damaged, and switching phone numbers. Another issue that arose during follow-ups with study participants was disapproval by the participants’ husbands of their participation in the study, leading a few participants to stop listening. Although this was not a widespread problem, it does indicate the challenge of implementing a tool for women in locations where men make decisions for their wives; however, women in these locations are likely to be in greater need of the information included in this tool.
In terms of lessons learned related to the evaluation, the report notes that the recruitment of participants into the study required specialised skills and a level of assiduity that are not typically needed for other types of surveys. The recruiters needed to understand that the study participants would be required to commit to receiving multiple programme calls and stay in the programme for up to three months. Moreover, recruitment required testing potential participants’ numeracy skills and Hausa linguistic skills. Failure on the part of recruiters to completely apply recruitment guidelines might have contributed to the initial failure of some participants to engage with the platform and for the high level of dropout along the way. In addition, in order to avoid potential attrition due to technical issues with the platform, intensive testing should be conducted prior to wide-scale use.
HC3 website on November 14 2017.