"mCenas! engaged young people aged 15-24 with an SMS-based role model story, in which characters were shown overcoming common barriers to contraceptive use faced by youth."
This Health COMpass Social and Behaviour Change Communication (SBCC) Spotlight describes the process and strategy of the mCenas! project in Maputo and Inhambane provinces, Mozambique. (See related summary below for more information.) From September 2013 - June 2014, Pathfinder International implemented the mCenas! (“Mobile Scenes”) project, "an interactive two-way SMS system, accessible at no cost to clients. The goal of mCenas! was to reduce the barriers youth face in starting or continuing to use contraception by increasing their knowledge of and dispelling common myths about contraceptive methods."
In addition to story engagement on sexual and reproductive health through SMS text messages on mobile phones, "youth could also access a menu-based message system on their phone and were prompted to call a Ministry of Health- supported hotline, where live operators were poised to answer their questions."
The Inquire phase used analysis of surveys to develop baseline statistics, which showed the team "the need for young people to receive information about contraception and contraceptive services, as well as the need to work with youth to identify strategies to overcome the multiple barriers they face in seeking contraceptive services and using contraception to delay or space pregnancies....[using] the Pathfinder...Pathways to Change tool...to gather information from the target population about the barriers to and facilitators of contraceptive use, and to generate initial story ideas...[f]ourteen 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."
In the "Design your Strategy" phase, the team made "use of narrative (or stories) in order to present information in a format that can contextualize and highlight multiple dimensions of behavior...to not only provide information to youth, foster reflection, and generate strategies to overcome barriers and maximize facilitators for use of contraceptive and other sexual and reproductive health (SRH) services."
In the "Create and Test" phase, a "Mozambican scriptwriting consultant was involved and she, together with the visiting Pathfinder HQ advisor identified the top two to three barriers and facilitators around which to build the story." Pretesting began with staff reading groups, then the creation of 24 chapters for each storyline, another review for behaviour change communication (BCC) content, and translation to Portuguese, SMS formatting using local texting abbreviations and expressions, and then a pretest for comprehensibility in each province with focus groups. These groups formulated message topics around sexuality and questions frequently asked by youth to add, then the draft messages went to the Ministry of Health (MOH) and stakeholders. A hotline and staff operator training was also implemented.
The "Mobilize and Monitor" phase began with sending three messages a week for two months using one story for readers with children and one for readers without children. In the third month, contraceptive information was sent three times a week. The mCenas! site and mobile app, which offered a contraceptive method information menu and a list of Frequently Asked Questions (FAQs), were continually available. "Mobilization also included training of 20 peer educators from two youth community-based organizations in Matola and Inhambane on how to register to receive messages, as well as outreach activities held at secondary schools and in communities. The outreach activities included a door to door campaign, health fairs, and community events. In order to enroll in mCenas!, the individual needed to be between 15-24 years of age, have a cellphone of their own, and have minimum skills in using text SMS."
The "Evaluate and Evolve" phase yielded the following data: Knowledge about contraception rose from 74.4% of females with children and 59.9% of females without children to 86.6% and 73.9% respectively at endline, with increased perceptions on safety, ease of use, and effectiveness. Contraceptive use (ever use and current use) increased statistically significantly only for combined oral pill and emergency contraception (only among females with children). Contraception attitudes, beliefs, and outcome expectations changed during the intervention: Youth were better informed and fears of use declined, and belief in increased opportunity was higher in youth without children. Potential barriers to contraceptive use were not reflected in attitudes/condition of respondents at baseline or endline. Measures of acceptability of mCenas! included participant satisfaction, comfort with receiving/sending messages and willingness to receive SRH messages in the future, satisfaction with pace and length of messages, and willingness (90%) to pay for future SRH messages.
Lessons learned include:
- "Give it Time - ...To maximize the benefits of mobile phone interventions, they may need to be implemented over a relatively long period of time to give beneficiaries sufficient time to process and act on the information they receive. It usually takes time to translate knowledge to practice....
- Focus on Safety and Effectiveness - Consider focus on safety and effectiveness of methods of contraceptive methods,...potentially including comparative effectiveness of methods.
- Address Self-Efficacy - Address self-efficacy among female youth....Subsequent mobile phone interventions should devote significant effort to addressing self-efficacy among female youth by reviewing messages to ensure an emphasis on building confidence to seek and use contraception services, and by complementing mHealth with community activities, such as face-to-face communication with peers and peer educators, which can include role play and coaching. Also, there needs to be better understanding of the reasons for low self-efficacy for contraceptive use among young women, and where gender inequity is implicated, interventions should involve young men.
- Assessing the Value of mHealth Efforts - Design mHealth studies to permit an assessment of the relative contribution of the mobile phone application to improvements in knowledge, attitudes, and self-efficacy related to contraception....A design that permits a comparison of an integrated program with a standalone program would have permitted a richer assessment of these elements.
- Sustainability - Explore how interventions like mCenas! can be implemented and sustained in Mozambique. The overwhelming majority of respondents expressed acceptance of mCenas!, implying that SRH messages delivered through this channel have high probability of reaching youth....Use Stories - Use stories delivered via SMS to reach young people with SRH content. Findings from the assessment suggest that longer fictional narratives delivered via SMS are a feasible and acceptable way of reaching young people with SRH content. The use of realistic stories to complement informational messages may have contributed to young people’s engagement with the intervention and the positive findings."
- Use Stories - Findings from the assessment suggest that longer fictional narratives delivered via SMS are a feasible and acceptable way of reaching young people with SRH content. "The use of realistic stories to complement informational messages may have contributed to young people’s engagement with the intervention and the positive findings."
Health COMpass website, July 24 2015.