Mobile Technology for Improved Family Planning (MOTIF): the development of a mobile phone-based (mHealth) intervention to support post-abortion family planning (PAFP) in Cambodia

Perceptions of community health workers on teenage pregnancy in rural Limpopo: A qualitative study

BACKGROUND

 Despite measures put in place to combat teenage pregnancy, the rate remains high. Community health workers (CHWs) are a cadre of health workers that can help put measures in place to reduce teenage pregnancy in the communities in which they live and work.

AIM

 This article aims to gain a deeper understanding of CHWs' perceptions regarding teenage pregnancy in the rural districts of Limpopo province.

METHODS

 An exploratory qualitative study approach was employed to collect data from CHWs in two rural districts of Limpopo. A non-probability purposive sampling approach was used to choose 81 CHWs. Eight focus group discussions (FGDs) were organised, and audio recorded to collect data from participants. The discussions were 2-3 h long and conducted in English, and data saturation was attained by the fifth FGDs.

RESULTS

 An eight-step tech's content analysis approach was employed to deductively code, analyse and summarise data into themes. Three themes emerged: the prevalence of teenage pregnancy in rural villages, factors contributing to teenage pregnancy and challenges faced by CHWs when dealing with teenage pregnancy.

CONCLUSION

 The study's findings revealed that CHWs face challenges in their communities when offering appropriate teen pregnancy services and CHWs believe that teen pregnancy numbers remain high. There is a significant barrier in combating teenage pregnancy; if contraceptives are not acceptable to the community, the only solution and option for combating teenage pregnancy is abstinence.Contribution: The CHWs presented their insights of teenage pregnancy in rural communities. The outcomes of this study could help clinical practise, schools, communities, youth-friendly services, policymakers and other non-governmental organisations reduce teenage pregnancy.

Obstetric fistula repair failure and its associated factors among women who underwent repair in sub-Saharan Africa. A systematic review and meta-analysis

BACKGROUND

Obstetric fistula repair failure can result in increased depression, social isolation, financial burden for the woman, and fistula care programs. However, there is limited, comprehensive evidence on obstetric fistula repair failure in Sub-Saharan African countries. This systematic review and meta-analysis aimed to determine the pooled prevalence of obstetric fistula repair failure and associated factors among women who underwent surgical repair in Sub-Saharan African countries.

METHODS

To identify potential articles, a systematic search was done utilizing online databases (PubMed, Hinari, and Google Scholar). The Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA) guideline was used to report the review's findings. I2 test statistics were employed to examine study heterogeneity. A random-effects model was used to assess the pooled prevalence of obstetric fistula repair failure, and the association was determined using the log odds ratio. Publication bias was investigated using the funnel plot and Egger's statistical test at the 5% level of significance. Meta-regression and subgroup analysis were done to identify potential sources of heterogeneity. The data were analyzed using STATA version 17 statistical software.

RESULTS

A total of 24 articles with 9866 study participants from 13 Sub-Saharan African countries were included in this meta-analysis. The pooled prevalence of obstetric fistula repair failure in sub-Saharan Africa was 24.92% [95% CI: 20.34-29.50%]. The sub-group analysis by country revealed that the highest prevalence was in Angola (58%, 95% CI: 53.20-62.80%) and the lowest in Rwanda (13.9, 95% CI: 9.79-18.01%). Total urethral damage [OR  =  3.50, 95% CI: 2.09, 4.91], large fistula [OR = 3.09, 95% CI: (2.00, 4.10)], duration of labor [OR = 0.45, 95% CI: 0.27, 0.76], and previous fistula repair [OR = 2.70, 95% CI: 1.94, 3.45] were factors associated with obstetric fistula repair failure.

CONCLUSION

Women who received surgical treatment for obstetric fistulas in Sub-Saharan African countries experienced more repair failures than the WHO standards. Obstetric fistula repair failure was affected by urethral damage, fistula size, duration of labor, types of fistula, and history of previous repairs. Therefore, we suggest policy measures specific to each country to provide special attention to the prevention of all risk factors, including poor nutrition, multiparty, obstructed labor, and maternal age, which can result in conditions like large fistulas, urethral damage, and repeat repair, in order to reduce obstetric fistula repair failure.

The Effect of School-Linked Module-Based Friendly-Health Education on Adolescents' Sexual and Reproductive Health Knowledge, Guji Zone, Ethiopia - Cluster Randomized Controlled Trial

Background

Although access to sexual and reproductive health information is the right and a critical component of health policy, it is not well addressed in pastoral communities. This study assessed the effect of School-Lined Module-based friendly health education on adolescents' sexual and reproductive health knowledge in the pastoral community of Guji Zone, Ethiopia.

Methods

A two-arm cluster Randomized control trial study with pre-post evaluation was conducted among interventions (n=375) compared with control (n=384) in Gorodola and Wadara high schools. Comparing an intervention to a control group, pre-posttests, and post-posttests were used to evaluate the effectiveness of the intervention. The data was collected using 25 Self-administered questionnaires and analyzed using paired-sample independent t-tests and linear regressions to study the relationship between the outcome and independent variables.

Results

We collected the data from 759 adolescents among 15 intervention and 15 control clusters. The results have shown that as compared to control arms, the mean sexual and reproductive health Knowledge score was significant higher in the intervention clusters (375) 73.3%, vs (384) 66.5%%, p<0.001, 95% CI, (0.05395-0.08347). Information (β: 0.038, 95% CI: 0.028-0.052), confidence (β: 0.045, 95% CI: 0.033-0.057), knowledge (β: 0.05, 95% CI: 0.035-0.066), and compassionate care (β: 0.107, 95% CI: 0.092-0.122) were significantly associated with SRH knowledge prediction. The proportion of SRH knowledge increased from 168(44%) baseline to 244(65%) end line in the intervention versus 235(60% to 238(62%) in control arms.

Conclusion

The execution of school-linked module-based friendly health education has proved to have a significant effect on mean SRH knowledge. Individual-level and behavioral-level factors significantly explain variability in enhancing SRH knowledge in the pastoral community. We recommend scaling up the School-Linked Module-based friendly health education intervention.

Trial Registration

We registered clinical trial PACTR202107905622610 on 16 July 2021.

Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care After Surgical Abortion (the FACTS Study Phase 3): Mixed Methods Prospective Pilot Study

BACKGROUND

In Canada, 1 in 3 women and people of gestational age undergo an abortion in their lifetime. Despite the liberal legal context, barriers continue to exist for women and people who can become pregnant to access this service.

OBJECTIVE

This study aims to (1) conduct a pilot study to demonstrate the feasibility and acceptability of myPostCare to support follow-up care after a procedural abortion; (2) use the findings to understand whether myPostCare has the potential to improve contraceptive behavior and knowledge, emotional well-being, and sexual health knowledge; and (3) develop a better understanding of how innovative mobile solutions can support integrative health programs in British Columbia with the goal of expanding to other sites across Canada.

METHODS

People of gestational age (aged 14-45 y) who underwent a procedural abortion were recruited from 2 urban abortion facilities in British Columbia. The participants completed a baseline quantitative survey and were provided access to myPostCare for up to 30 days. A follow-up quantitative survey was sent via email on day 30. Qualitative interviews were conducted to explore user satisfaction and usability of myPostCare. Responses to the survey questions were summarized using descriptive statistics, and the system usability scale (SUS) was scored according to the instructions. A secure analytics platform was implemented to obtain data on the overall use of the website by users. Qualitative analysis was conducted with NVivo using a thematic analysis approach. This study was approved by the Women's and Children's Research Ethics Board.

RESULTS

Overall, 62 participants were recruited (average age 30 y); 40% (25/62) of the participants completed the exit surveys, and 24% (6/25) consented to participate in the semistructured interviews; 40 participants had undergone an immediate postabortion intrauterine device (IUD) insertion, and 22 did not have an IUD inserted. Participants were satisfied with myPostCare. The SUS average score was 81.5 (SD 9.7; median 82.5, IQR 77.5-87.5), indicating high usability of the tool. Overall, 88% (22/25) of the participants changed their contraceptive method to an IUD. Web-based analytics demonstrated that there were 61 unique visitors to the site, and the top pages visited were Postprocedure Care, Emotional Well-Being, and Contraception Explorer. The longest time spent on the website was 56 minutes. The overall email open rate was 80%, with a click rate of 36%.

CONCLUSIONS

This study demonstrates that communities and individuals are important collaborators in developing a mobile innovation that facilitates access to high-quality patient-centered abortion care. Through the cocreation process, a digital platform such as myPostCare highlighted a gap in abortion care in Canada, particularly around follow-up support after a procedural abortion.

i-MoMCARE: Innovative Mobile Technology for Maternal and Child Health Care in Cambodia-study protocol of a cluster randomized controlled trial

BACKGROUND

The Government of Cambodia established the village health support groups (VHSGs) in 2003 to facilitate primary healthcare activities, including maternal and child health (MCH) services. However, VHSGs face several challenges that hinder them from performing optimally, including a lack of regular structured training and remuneration and limited and inconsistent support and supervision from the health centers (HCs). This implementation research aims to develop, implement, and evaluate a digital health intervention to improve the performance of VHSGs through better support and supervision and increase the MCH service coverage in rural Cambodia.

METHODS

i-MoMCARE, a two-arm cluster randomized controlled trial, will be conducted between 2022 and 2025. Five operational districts (ODs) have been randomized to an intervention arm and the other five ODs to the control arm. The intervention will last for 24 months. Around 200 VHSGs in the intervention arm will be equipped with a mobile application as a job aid and 20 HC staff with a web interface to improve support and supervision of VHSGs. The potential beneficiaries will include pregnant women, mothers, and children under 2 years old. We will measure the outcomes at baseline and endline. The primary outcomes will consist of a composite MCH index constructed from maternal and newborn care indicators, child immunization, and treatment of under-two children. Secondary outcomes will include coverage of selected MCH services. We will conduct the intention-to-treat and per-protocol analyses. We will conduct qualitative interviews with selected beneficiaries and stakeholders to evaluate the intervention's acceptability, feasibility, and scalability. We will also conduct a cost-effective analysis using decision-analytic modeling incorporating a societal perspective that explores different time horizons, intervention effects, and when scaled up to the national level.

DISCUSSION

i-MoMCARE is expected to increase MCH service access and coverage in rural Cambodia. It will contribute to advancing digital health use in primary healthcare interventions, which remains in its infancy in the country. Furthermore, the study findings will be a valuable addition to a growing body of literature on the effectiveness and feasibility of mobile health to improve coverage of MCH services in rural low- and middle-income country settings.

TRIAL REGISTRATION

ClinicalTrial.gov NCT05639595. Registered on 06 December 2022.

Predictors of fertility awareness among selected married women of childbearing age in Nigeria: a cross-sectional survey

Background

Increased fertility awareness can help infertile couples to achieve pregnancy.

Objectives

This study aimed to determine both the predictors and levels of fertility awareness among married Nigerian women of childbearing age.

Methods

A nationwide cross-sectional survey. Data were collected via online and face to face questionnaires. Descriptive and inferential analysis were done with SPSS 25.

Results

Most respondents married between ages 24-29 years old (40%) and just over half had good fertility awareness (53%). The associated factors were age at menarche (X2 = 9.962, p = 0.007), geopolitical zone of residence (X2 = 17.301, p = 0.008), level of education (X2 = 64.843, p < 0.001), employment status (X2 = 9.319 p = 0.025) menstrual cycle charting (X2 = 66.392, p < 0.001), use of internet to increase awareness (X2 = 39.849, p < 0.001) and books (X2 = 58.855, p < 0.001). Fertility awareness was lower for those with secondary education than postgraduates (AOR=0.213, 95% CI 0.116-0.390, p < 0.001). Moreover, the odds of having good fertility awareness were less in those who did not chart their menstrual cycle (AOR=0.363, 95% CI 0.245-0.538, p < 0.001).

Conclusion

Menstrual cycle charting and level of education were predictors of fertility awareness.

The Role of Electronic Health Tools in Unwanted Pregnancy Prevention, Abortion and Post-Abortion Follow-Up: A Systematic Review

Background

More than 30% of women experience at least one abortion. To date, there has been no comprehensive mobile health project on the impact of technology on access to abortion, contraception, and post-abortion follow-up. The purpose of this study was to review published studies on the role of electronic health in the prevention of unwanted pregnancy, abortion, and post-abortion follow-up.

Materials and Methods

The Web of Science, PubMed, ScienceDirect, and EMBASE databases were searched to find relevant articles published between 2008 and 2018. A systematic review study was conducted on 33 relevant articles. All studies related to the use and impact of electronic health on unwanted pregnancy prevention, abortion and post-abortion follow-up in English from January 2008 to December 2018 were included. The quality of the studies was evaluated using the PRISMA-S.

Results

Thirty-three studies met the inclusion criteria for the review. The Studies were divided into four main groups of women's experiences on the use of mobile health and telemedicine technologies for at-home medical abortion, unwanted pregnancy prevention, abortion, and post-abortion follow-up. The results showed the significant impact of using electronic health on unwanted pregnancy prevention, abortion, and post-abortion follow-up.

Conclusions

Health technologies have the potential to be used as a low-cost and accessible method to replace abortion services. They can facilitate remote care and quick access to information to complete the gaps in access to abortion. Therefore, it is necessary for health service providers to be aware of the possibility of the client's access to electronic health tools.

Discontinuation Rate of Intrauterine Device and Associated Factors Among Women in the Last One Year in Angacha District, Southern Ethiopia

Background

Discontinuation of intrauterine contraceptive device is the phenomenon of starting a contraceptive method and then ending it within one year of its use. Discontinuation of an intrauterine contraceptive method often leads to unintended pregnancy; this tips to potentially unsafe abortions and unintended births. Even though Ethiopian government gives an attention to long acting reversible contraceptives, especially IUCD, there are no recent studies conducted in the study area. Thus, this study aimed to assess the discontinuation rate of IUCD and associated factors among women in the last one year in Angacha District, southern Ethiopia.

Methods

A community-based cross-sectional study was conducted from June 22 to July 22, 2020. Multistage sampling was used to select a total of 596 women who used IUCD during the last year in the Angacha district. Data were collected using pre-tested structured questionnaires. The collected data were entered into Epidata version 3.1 and exported to SPSS version 23 for analysis. Multivariate logistic regression analysis was carried out to identify factors independently associated with discontinuation IUCD. The significance level was set at a p-value of <0.05 and AOR with 95% CI was used to interpret the association.

Results

In this study, 116(19.5%) women discontinued the use of IUCD in the last year with a 95% CI of 16.3%-22.5%. Counseling before IUCD insertion [AOR (95% CI) = 2.5(1.03, 6.03)], marital status [AOR (95% CI) = 0.23(0.08, 0.69)], access to IUCD service [AOR (95% CI) = 0.29(0.12, 0.72)], and parity [AOR (95% CI) = 3.69(1.97, 8.84)] were significant with discontinuation of IUCD.

Conclusion

The overall magnitude of IUCD discontinuation in the study area was found to be high. Counseling before IUCD insertion and parity were positively associated while marital status of mothers and access to IUCD services were negatively associated with the discontinuation of IUCD.

Epidemiology and Histopathology of Nasopharyngeal Neoplasms in Iran

Introduction

This study aimed to study the trend, histologic pattern, geographical distribution, and characteristics of nasopharyngeal carcinoma (NPC) and nasopharyngeal neoplasms (NPN) from 2003 to 2017 in Iran.

Materials and Methods

The Ministry of Health and Medical Education collected NPN cases from the corresponding university in each province and stored them in Iran National Cancer Registry (INCR) database. The Joinpoint program calculated the average annual percent change (AAPC) and its 95% confidence interval (CI). The jump model minimized the interfering effect of INCR transformation.

Results

3653 NPN cases were reported between 2003-2010 and 2014-2017, with a mean age of 49.04 ± 18.31 years and a male-to-female ratio of 2.15. The age-standardized incidence rate (ASIR) per 100,000 person-years was 0.30 for females and 0.68 for males in 2017. Although the ASIR/100,000 of NPN raised from 0.35 to 0.49 during 2003-2017, the trend was constant with an AAPC of -2% (95% CI: -4.8% to 0.9%). The age-specific incidence rate was highest in the older than 70 population (1.56/100,000). NPC formed 77.1% of NPNs and showed a constant pattern (AAPC CI: -5.7% to 0.2%), in contrast to the significant increase of non-keratinizing squamous cell carcinoma (AAPC CI: 2.3%to 24.5%).

Conclusions

Nasopharynx cancer is rare in Iran, and NPC incidence remained constant from 2003 to 2017, unlike previously reported rising trend. However, non-keratinizing squamous cell carcinoma exhibited a significant increase, and future studies are needed to examine the role of the Epstein-Barr virus on this growth rate.

Women's perceptions about mobile health solutions for selection and use of family planning methods in Karachi: a feasibility study

BACKGROUND

The qualitative study explored the feasibility and acceptability of potential mHealth intervention for women living in low socio-economic areas to increase the uptake of family planning. The study also examined providers' perceptions' potential benefits of mHealth intervention.

METHODS

The qualitative exploratory study recorded the perception of 23 women and conducted seven in-depth interviews with the providers of family planning services. These interviews assessed women's attitudes through; personal experience based on the usage of smartphones and family planning, acceptability for personal benefits, features of mobile applications and the convenient language, and self-efficacy for identifying the potential impact of mHealth intervention to increase women's empowerment for family planning usage.

RESULTS

Three predetermined themes were used to record women's perceptions. Women's personal experience identified that women in low-socioeconomic areas use mobile phones frequently and also use them for gaining information related to health. Few women have experience using mobile phones to get information about sexual and reproductive health. Women considered; poor counselling and high transport costs to the facilities as significant barriers to getting family planning services. Perceived acceptability discussed the potential features of the mHealth app. Women considered that including short videos instead of written material would help them to understand its usage and complete information about family planning methods, including; dosage, expected side effects, and potential benefits suggested to include in the app. Women perceived that the mHealth intervention would save their transport costs to the facility and fill the information gap about family planning methods. In comparison, providers considered it would save time in counselling and motivating women at the facility. One of the significant factors discussed was self-efficacy in the form of women's empowerment in deciding on family planning. Women discussed that the mHealth intervention would increase their self-confidence to discuss the method with their husbands.

CONCLUSION

There is a high potential for mHealth interventions for family planning in Pakistan. The usage of mobile phones can increase women's acceptability and accessibility for family planning uptake in the country.

Perceptions of the use of mobile phones to access reproductive health care services in Tamale, Ghana

Introduction

Africa has one of the world's highest populations of young people. In addition, Africa has one of the highest proportions of young people facing the worst health challenges. Although previous scholars have reported that young people were using mobile phones to fill in the gaps in accessing reproductive health services, among other health services, there was little comprehensive research on the perception of young people in Tamale, Ghana, on the use of mobile phones to access reproductive health services. This study analyzed the perceptions on mobile phone use to access reproductive health services among young people in Tamale, Ghana.

Methods

The research used a quantitative method design from a target population of 72,706 young people from selected peri-urban, low-income, middle income and high-income residential areas in Tamale Metropolis, Ghana. The sample size used was 397 young people. Participants were selected using a stratified multistage sampling strategy. Descriptive statistics were used to analyse the data.

Results

A total of 86% of the respondents agree that the use of mobile phones helps to overcome cultural challenges that young people in Tamale encounter in accessing reproductive health care. Also, 84.6% of the respondents agree that the use of mobile phones helps them to overcome inadequate access to reproductive health information and services. The use of mobile phones helps to overcome the negative attitude of health providers toward young people in need of reproductive health services was agreed by most of the respondents [strongly agree (35.4%) and agree (49.4%)].

Conclusion

This study informed highly positive perceptions and attitudes toward the use of mobile phones to access Reproductive Health Services in Tamale, Ghana. There is, therefore the need for the health sector to reform its mode of prescriptions of medication, consultation, and service delivery to leverage on the advantages that mHealth presents.

Prevalence and correlates of erectile dysfunction among long-distance commercial vehicle drivers and commercial motorcycle riders in Ibadan Nigeria: a comparative cross-sectional study

Background

Erectile dysfunction (ED) is a global public health problem that affects the quality of life, interpersonal, occupational, and social functioning of sufferers. Despite being high-risk groups, there is a paucity of data on erectile dysfunction among commercial vehicle drivers and motorcycle riders.

Objectives

We aimed to determine and compare the prevalence and factors associated with ED among long-distance commercial vehicle drivers (CVDs) and commercial motorcycle riders (CMRs) in Ibadan, Nigeria.

Methods

We used a comparative cross-sectional study design to enroll eligible male respondents in selected motor/motorcycle parks within Ibadan metropolis. Interviewer administered questionnaires were used to elicit sociodemographic/health-related characteristics, and ED status among participants. Data was analyzed using STATA version 12. Chi-square and Binary logistic regression were conducted to explore the association between ED and other covariates. Analyses were performed at 5% significance level.

Results

The prevalence of ED was significantly higher among motorcycle riders than vehicle drivers (71.4% vs 47.4%, p = 0.001). Predictors of ED among CMRs were monogamous marriage type and history of perineal injury; while among CVRs were aged above 40-years, history of perineal injury, and current use of alcohol.

Conclusion

There is a need for public education and awareness programmes on ED to reduce the burden and improve well-being in these populations.

Barriers and facilitators regarding the implementation of policies and programmes aimed at reducing adolescent pregnancy in Ghana: an exploratory qualitative study

OBJECTIVES

This study explored the perceived barriers and facilitators regarding the implementation of policies and programmes aimed at reducing adolescent pregnancy among health and education professionals ('professionals'), grassroots workers and adolescent girls in Ghana.

DESIGN AND SETTING

We employed an exploratory qualitative study design involving interviews with professionals, grassroots workers and adolescent girls in the Central Region of Ghana.

PARTICIPANTS

This study involved 15 professionals employed in government or non-governmental organisations, 15 grassroots workers and 51 pregnant/parenting and non-pregnant adolescent girls.

DATA ANALYSIS

Thematic analysis was conducted deductively using the ecological framework for understanding effective implementation.

RESULTS

Eighteen themes mapped to the five domains of the ecological framework emerged. Perceived barriers included gender inequality, family poverty, stigma, community support for early childbearing and cohabitation, inadequate data systems, lack of collaboration between stakeholders and lack of political will. Effective implementation of community by-laws, youth involvement, use of available data, and collaboration and effective coordination between stakeholders were the perceived facilitators.

CONCLUSION

Political leaders and community members should be actively engaged in the implementation of adolescent sexual and reproductive health policies and programmes. Gender empowerment programmes such as education and training of adolescent girls should be implemented and strengthened at both the community and national levels. Community members should be sensitised on the negative effects of norms that support child marriage, gender-based violence and early childbearing.

Exploring the reproductive health needs of men in the preconception period: A qualitative study

BACKGROUND

Male reproductive health is a necessary pillar of childbearing. If a reproductive health assessment is conducted in the preconception period, the chance of a healthy pregnancy can increase. This qualitative study aimed to explore men's reproductive health needs before conception in Iran.

MATERIALS AND METHODS

This research was a qualitative study conducted in Bushehr city, Iran to explore men's reproductive health needs from April 2021 to November 2021. 30 semistructured interviews were conducted with married men, women, healthcare providers, and specialists individually in the health centers. The sampling method used in this study was purpose-based with maximum variety. All interviews were digitally recorded and transcribed verbatim in Persian and analyzed using directional content analysis. MAXQDA software version 12 was used to facilitate data analysis.

RESULTS

From the data analysis, 2 themes, 15 categories, and 38 subcategories emerged. The themes included evaluation and health promotion recommendations. It consisted of 10 categories: reproductive life plan evaluation, medical history evaluation, family and genetic history evaluation, social history evaluation, sexual health evaluation, medication evaluation, laboratory evaluation, physical examination, lifestyle evaluation, and mental health evaluation. Health promotion recommendations included five categories: nutritional recommendations, stress management, avoiding harmful behaviors, protective measures against harmful exposure, and need for education.

CONCLUSIONS

Our results showed that men need a comprehensive evaluation of reproductive health and recommendations to improve their health in the preconception period. Our study findings can inform healthcare providers to increase men's participation in reproductive health.

Link between unmet need and economic status in Bangladesh: gap in urban and rural areas

Background

Unmet need for family planning (FP) is a core concept in designing FP programmes and reduction of unmet need for FP can improve reproductive and maternal health services. Bangladesh is still away from achieving the target regarding unmet need for FP. This study aimed to explore the composite effect of economic status and place of residence on unmet need for FP among currently married women of reproductive age in Bangladesh after controlling the effect of other selected covariates.

Methods

The study used the data extracted from the Bangladesh Demographic and Health Survey (BDHS) 2017–2018, which is a nationally representative survey implemented using a stratified two-stage cluster sample design. A total of 13,031 currently married women of reproductive age were included in the final analysis. Binary logistic regression model has been employed to identify the factors influencing the unmet need for FP. Model-I investigated the effect of composite variable place-wealth on unmet need for FP and Model-II examined the effect of place-wealth on unmet need for FP after adjusting for the effect of other selected covariates. The Odds Ratios with p-values were reported to identify significant covariates.

Results

The rate of unmet need for FP was 15.48%. The composite factor of economic status and place of residence had significant influence on unmet need for FP in both models. Generally, rural women were significantly more likely to have unmet need for FP than their urban counterparts. In particular, women from rural areas and belong to rich families had the highest likelihoods of unmet need for FP. The other selected covariates also had significant influence on unmet need for FP.

Conclusion

This study shows that rural women had higher odds of unmet need for FP than urban women. The healthcare providers and stakeholders should take necessary actions to motivate women to use contraceptive specially the women who are residing in the rural areas.

Intimate partner violence and timely antenatal care visits in sub-Saharan Africa

BACKGROUND

Intimate partner violence (IPV) during pregnancy has negative physical and psychological health consequences on the pregnant women. As such, women who experience IPV during pregnancy are likely to have challenges accessing maternal healthcare services. In this study, we examined the influence of exposure to IPV on timely antenatal care (ANC) visits in sub-Saharan Africa.

METHODS

Cross-sectional data from the most recent Demographic and Health Survey of twenty-two countries in sub-Saharan Africa between 2012 and 2020 were analysed. Data were obtained from 61,282 women with birth history in the five years prior to the survey. A multilevel logistic regression was used to determine the association between IPV and timely ANC visits while controlling for significant covariates. Adjusted odds ratios (aOR) with 95% Confidence Intervals (CI) were used to present results from the multilevel logistic regression analysis.

RESULTS

The prevalence of timely ANC visit and IPV were 38.1% and 34.9% respectively. The highest and lowest prevalence of IPV were found in Sierra Leone (52.9%) and Comoros (8.1%), respectively. Timely ANC attendance among pregnant women was more prevalent in Liberia (74.9%) and lowest in DR Congo (19.0%). Women who experienced IPV during pregnancy were less likely to utilize timely ANC (aOR = 0.89, 95% CI = 0.86-0.92) compared to those who did not experience IPV. In terms of the covariates, the odds of timely ANC were higher among women aged 40-44 compared to those aged 15-19 (aOR = 1.35, 95% CI = 1.21-1.51). Higher odds of timely ANC was found among women who were cohabiting (aOR = 1.15, 95% CI = 1.10-1.20), those from the richest wealth quintile (aOR = 1.38, 95% CI = 1.28-1.48), those exposed to watching television (aOR = 1.24, 95% CI = 1.18-1.30), and those with health insurance (aOR = 1.46, 95% CI = 1.37-1.56).

CONCLUSION

Findings from the study indicate the role of IPV in timely ANC visit in sub-Saharan Africa. To enhance timely ANC visits, there is the need for policy makers to strengthen and enforce the implementation of policies that alleviate IPV during pregnancy. Education and sensitization of married and cohabiting women and men on the negative effects of IPV on timely ANC should be done using media sources such as television. Inequalities in timely ANC can be eliminated through the provision and strengthening of existing maternal health policies such as health insurance.

Analyzing program data and promotional approaches to inform best practices from a mobile phone-based reproductive health message program in Afghanistan

Objective

Digital health technologies have contributed to the adoption of beneficial reproductive, maternal, newborn, and child health (RMNCH) behaviors through social and behavior change programming, including in hard-to-reach settings. On-demand digital health interventions rely on promotions to build awareness and increase use among target audiences. There is little research on preferred content and use of promotional approaches for RMNCH digital health activities.

Methods

We conducted a retrospective descriptive analysis of Mobile for Reproductive Health (m4RH) data in Afghanistan to assess the use and changes in call volume via the 2-3-4 platform by promotional approaches over 23 months between October 2017 and August 2019.

Results

There were 103,859 completed messages (CM) heard. Most callers reporting demographics were under 18 years, with roughly even distribution by gender. The number of CMs listened to across all menus increased with time. The basic m4RH family planning menu was most popular, with callers most frequently selecting information on intrauterine contraceptive devices. Nine types of promotional approaches were implemented. Compared against call volume, SMS blast promotion was the most productive promotional approach, radio broadcasts had modest increases, and social media and interpersonal communication demonstrated no clear change.

Conclusions

m4RH use increased over time, particularly among younger people. The number of promotional approaches used does not appear as important as the type of approach used to generate program awareness. Mass media communications, including SMS blast promotions and radio broadcasts, may be the most effective strategies. Deeper program data analysis can guide tailoring of message content and promotional approaches to reach target audiences with the RMNCH content they most value.

Experiences of private sector quality care amongst mothers, newborns, and children in low- and middle-income countries: a systematic review

Background

Experience of care is a pillar of quality care; positive experiences are essential during health care encounters and integral to quality health service delivery. Yet, we lack synthesised knowledge of how private sector delivery of quality care affects experiences of care amongst mothers, newborns, and children. To fill this gap, we conducted a systematic review that examined quantitative, qualitative, and mixed-methods studies on the provision of maternal, newborn, and child health (MNCH) care by private providers in low- and middle-income countries (LMICs). This manuscript focuses on experience of care, including respectful care, and satisfaction with care.

Methods

Our protocol followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Searches were conducted in eight electronic databases (Cumulative Index to Nursing and Allied Health, EconLit, Excerpta Medica Database, International Bibliography of the Social Sciences, Popline, PubMed, ScienceDirect, and Web of Science) and two websites and supplemented with hand-searches and expert recommendations. For inclusion, studies examining private sector delivery of quality care amongst mothers, newborns, and children in LMICs must have examined maternal, newborn, and/or child morbidity or mortality; quality of care; experience of care; and/or service utilisation. Data were extracted for descriptive statistics and thematic analysis.

Results

Of the 139 studies included, 45 studies reported data on experience of care. Most studies reporting experience of care were conducted in India, Bangladesh, and Uganda. Experiences of private care amongst mothers, newborns, and children aligned with four components of quality of care: patient-centeredness, timeliness, effectiveness, and equity. Interpersonal relationships with health care workers were essential to experience of care, in particular staff friendliness, positive attitudes, and time spent with health care providers. Experience of care can be a stronger determining factor in MNCH-related decision-making than the quality of services provided.

Conclusion

Positive experiences of care in private facilities can be linked more broadly to privileges of private care that allow for shorter waiting times and more provider time spent with mothers, newborns, and children. Little is known about experiences of private sector care amongst children.

Trial registration

This systematic review was registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42019143383).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06905-3.

Knowledge and Information Exposure About Family Planning Among Women of Reproductive Age in Informal Settlements of Kira Municipality, Wakiso District, Uganda

Introduction: A high unmet need for family planning (FP) prevails in sub-Saharan Africa. Knowledge, awareness creation, and ensuring accessibility are frequently used to increase FP uptake. However, evidence on knowledge or information dissemination about FP among marginalized populations in urban settings in Africa is limited. This study explored the knowledge of FP methods, media exposure, and contact with FP providers among women from an informal settlement in Uganda.

Methods: Using a cross-sectional study design, we interviewed 626 women aged 15–49 years living in informal settlements of Kira municipality, selected through multistage sampling. Using a standard questionnaire, data was collected on socioeconomic characteristics, knowledge of FP methods, and access to media FP messages among others. Binomial log-linear regression was used to assess disparities in exposure to media FP messages or provider information. Data were analyzed using STATA version 14, at a 5% level of statistical significance.

Results: Nearly all women in the survey were aware of FP methods (99.7%). On average, each woman was aware of 10 FP methods. The most commonly known methods were male condoms (98.2%), injectables (97.4%), and the oral contraceptive pill (95.2%). Use of any contraceptive was found among 42.7% of respondents. Exposure to media was found in 70.6% of the respondents, mostly through television (58.5%) and radio (58.3%). Discussing FP with a provider was significantly associated with media exposure (aPR 1.4, 95% CI: 1.24–1.56). Less than 50% of women who were not using FP had contact with an FP provider. Women in union (aPR 1.6, 95% CI: 1.01–2.68) and those with access to media messages (aPR 2.5, 95% CI: 1.37–4.54) were more likely to have contact with a provider to discuss FP.

Conclusion: There is high general awareness about FP methods and media exposure, but method use was low. Further exploration of women's understanding of FP methods and the fit between existing education programs and FP knowledge needs in this urban setting should be conducted. The potential for mobile health solutions in this urban population should be explored. Future studies should focus on the knowledge and understanding of FP among unmarried and nulliparous women and those with no access to media information.

Development of an intervention to support reproductive health of garment factory workers in Cambodia: a qualitative study

OBJECTIVES

The aim of this study was to describe the development of an intervention to support the reproductive health of garment factory workers in Cambodia.

DESIGN

A qualitative study informed by intervention mapping which included semistructured interviews and participant observation, followed by intervention development activities including specifying possible behaviour change, designing the intervention, and producing and refining intervention content.

SETTING

The research was conducted by a multidisciplinary team with backgrounds in public health, linguistics, digital cultures and service delivery in a suburb of Phnom Penh where many garment factories cluster.

PARTICIPANTS

Garment factory workers in Cambodia; typically young women aged under 30 years who have migrated from rural areas to Phnom Penh city.

OUTCOMES

Analysis of reproductive health issues facing garment factory workers and metrics of videos developed.

RESULTS

Our research identified some challenges that Cambodian garment factory workers experience regarding contraception and abortion. Concerns or experience of side-effects were identified as an important determinant leading to non-use of effective contraception and subsequent unintended pregnancy. Financial constraints and a desire to space pregnancies were the main reported reasons to seek an abortion. Information about medical abortion given to women by private providers was often verbal, with packaging and the drug information leaflet withheld. In order to address limitations in the provision of accessible reproductive health information for factory workers, and given their observed widespread use of social media, we decided to make three 'edutainment' videos about family planning. Key social media metrics of the videos were evaluated after 1 month.

CONCLUSIONS

We describe the development of an intervention to support reproductive health among garment factory workers in Cambodia. These videos could be further improved and additional videos could be developed. More work is required to develop appropriate and effective interventions to support reproductive health of garment factory workers in Cambodia.

SMS-based family planning communication and its association with modern contraception and maternal healthcare use in selected low-middle-income countries

BACKGROUND

The objectives of this study were to 1) measure the percentage of women who received SMS-based family planning communication, and 2) its association with modern contraception and maternal healthcare services among mothers. In recent years, there has been a growing interest surrounding mobile phone-based health communication and service delivery methods especially in the areas of family planning and reproductive health. However, little is known regarding the role of SMS-based family planning communication on the utilisation of modern contraception and maternal healthcare services in low-resource settings.

METHODS

Cross-sectional data on 94,675 mothers (15-49 years) were collected from the latest Demographic and Health Surveys in 14 low-and-middle-income countries. The outcome variables were self-reported use of modern contraception and basic maternal healthcare services (timely and adequate use of antenatal care, and of facility delivery services). Data were analysed using multivariate regression and random effect meta-analyses.

RESULTS

The coverage of SMS-based family planning communication for the pooled sample was 5.4% (95%CI = 3.71, 7.21), and was slightly higher in Africa (6.04, 95%CI = 3.38, 8.70) compared with Asia (5.23, 95%CI = 1.60, 8.86). Among the countries from sub-Saharan Africa, Malawi (11.92, 95%CI = 11.17, 12.70) had the highest percent of receiving SMS while Senegal (1.24, 95%CI = 1.00, 1.53) had the lowest. In the multivariate analysis, SMS communication shown significant association with the use of facility delivery only (2.22 (95%CI = 1.95, 2.83). The strength of the association was highest for Senegal (OR = 4.70, 95%CI = 1.14, 7.33) and lowest for Burundi (OR = 1.5; 95%CI = 1.01, 2.74). Meta analyses revealed moderate heterogeneity both in the prevalence and the association between SMS communication and the utilisation of facility delivery.

CONCLUSION

Although positively associated with using facility delivery services, receiving SMS on family planning does not appear to affect modern contraceptive use and other components of maternal healthcare services such as timely and adequate utilisation of antenatal care.

Effect of a mobile phone-assisted postpartum family planning service on the use of long-acting reversible contraception: a randomised controlled trial

OBJECTIVE

The aim of the study was to evaluate the effect of adding mobile phone call reminders to a postpartum family planning service on the initiation of long-acting reversible contraception (LARC).

METHODS

A randomised, open-label controlled trial (ClinicalTrials.gov NCT03135288) was carried out at a university hospital between July 2017 and March 2019. The study comprised women who delivered a live birth at >28 weeks' gestation and who requested birth spacing for ≥1 year. Eligible women were recruited and randomised to two groups. The study group received contraceptive counselling and two reminders of their first postpartum appointment, one week and again 48 h before the appointment. The control group received contraceptive counselling but no mobile phone reminders of their first postpartum appointment. The primary outcome was the rate of initiation of a LARC method in the first 6 months postpartum.

RESULTS

The study comprised 500 participants in each group. The rate of initiation and continuation of a LARC method was significantly higher in the study group compared with the control group (30.2% vs 8.4% and 95.4% vs 83.3%, respectively; p < .001). In the study group, 382 (76.4%) women had started using a contraceptive method during the first 6 months, compared with 218 (43.6%) women in the control group (p < .001).

CONCLUSION

Using mobile phone reminders as part of the postpartum service increases the frequency of women who attends family planning clinics and initiates contraception, including a LARC methods, as well as the proportion who continue LARC use through the first 6 months postpartum.

Facilitators and barriers to the implementation of a Mobile Health Wallet for pregnancy-related health care: A qualitative study of stakeholders' perceptions in Madagascar

Financial barriers are a major obstacle to accessing maternal health care services in low-resource settings. In Madagascar, less than half of live births are attended by skilled health staff. Although mobile money-based savings and payment systems are often used to pay for a variety of services, including health care, data on the implications of a dedicated mobile money wallet restricted to health-related spending during pregnancy-a mobile health wallet (MHW)-are not well understood. In cooperation with the Madagascan Ministry of Health, this study aims to elicit the perceptions, experiences, and recommendations of key stakeholders in relation to a MHW amid a pilot study in 31 state-funded health care facilities. We conducted a two-stage qualitative study using semi-structured in-depth interviews with stakeholders (N = 21) representing the following groups: community representatives, health care providers, health officials and representatives from phone provider companies. Interviews were conducted in Atsimondrano and Renivohitra districts, between November and December of 2017. Data was coded thematically using inductive and deductive approaches, and found to align with a social ecological model. Key facilitators for successful implementation of the MHW, include (i) close collaboration with existing communal structures and (ii) creation of an incentive scheme to reward pregnant women to save. Key barriers to the application of the MHW in the study zone include (i) disruption of informal benefits for health care providers related to the current cash-based payment system, (ii) low mobile phone ownership, (iii) illiteracy among the target population, and (iv) failure of the MHW to overcome essential access barriers towards institutional health care services such as fear of unpredictable expenses. The MHW was perceived as a potential solution to reduce disparities in access to maternal health care. To ensure success of the MHW, direct demand-side and provider-side financial incentives merit consideration.

Perceived barriers and facilitators in using text and voice messaging for improving HIV and sexual and reproductive health of female entertainment workers in Cambodia: a qualitative study

BACKGROUND

Female entertainment workers (FEWs) in Cambodia are one of the hard-to-reach populations at risk of human immunodeficiency virus (HIV) and poor sexual and reproductive health (SRH). Due to the stigmatizing nature of their work, it is difficult to reach them with prevention and treatment services. The Mobile Link project is a mobile health (mHealth) intervention that aims to deliver health messages to FEWs and link them up to health services. This study aims to explore the perspectives of stakeholders on the Mobile Link and identify barriers and facilitators to the project implementation, in order to determine areas for improvement of future mHealth interventions.

METHODS

This study was conducted between November to December 2018 in the capital city and other three provinces where the Mobile Link was implemented. We employed a qualitative research design using an interpretative approach. A purposive sampling method was used to recruit participants across four project sites. All participants were stakeholders involved directly or indirectly with the Mobile Link. Nine different groups of stakeholders at the national, non-governmental organizations, community, and individual levels were recruited. Seventeen semi-structured in-depth interviews (IDIs) and five focus group discussions (FGDs) were conducted and transcribed. Data were managed using NVivo 12 and analysed using thematic analysis with an inductive approach.

RESULTS

We derived four major themes: (I) perceived benefits, (II) attitudes, (III) access, and (IV) enabling environment. Different levels of stakeholders reported on the perceived benefits of the Mobile Link, including ease of use, knowledge gained, link to services, and cost-effectiveness. Perceived benefits and enabling environment were identified as facilitators to implementation of the project. Barriers included technological issues, operational challenges, poor rapport with entertainment establishment owners, and low motivation to participate in the Mobile Link among FEWs.

CONCLUSIONS

The Mobile Link has many advantages and is well-accepted by stakeholders from the national and community levels. We discussed the implications of the perceived facilitators and barriers identified on the project and mHealth interventions. Implications discussed should be taken into consideration by organizations implementing mHealth interventions for HIV key populations in Cambodia as well as in other resource-limited settings.

Mobile phone ownership, text messages, and contraceptive use: Is there a digital revolution in family planning?

OBJECTIVES

This study aims to clarify the associations between mobile phone ownership use on family planning outcomes. Secondary analysis of DHS data finds that in certain contexts, mobile phone ownership may be related to increased FP uptake.

STUDY DESIGN

Using recent data for women 15-49 from the Demographic and Health Surveys for six countries - Ethiopia (2016), Uganda (2016), Tanzania (2015-16), Nepal (2016), Philippines (2017), and Haiti (2016-17) - we conduct multivariate logistic regression analysis to assess FP outcomes (contraceptive prevalence (CPR), modern contraceptive prevalence (mCPR), and unmet need for family planning) for mobile phone ownership and source of exposure to FP messaging. We use STATA14 for our analyses, and all results presented are weighted.

RESULTS

We find that in Uganda, Tanzania, and Haiti, owning a mobile phone is significantly associated with overall contraceptive use (OR = 1.38, 1.38, 1.23 respectively), modern contraceptive use (OR = 1.34, 1.30, 1.24 respectively) net of socioeconomic factors. Further, our analysis demonstrated that receiving FP information via text message was significantly associated with contraceptive uptake only in Haiti (OR = 1.62 for overall contraceptive use and OR = 1.53 for modern contraceptive use), where SMS systems have more robust connections to clinic services.

CONCLUSIONS

Our results indicate that in certain contexts, mobile phone ownership may be related to increased FP uptake.

IMPLICATIONS

These findings help inform investments in mHealth programming for family planning and reproductive health. They help clarify the potential significance of demographic patterns of mobile ownership and health outcomes, and also demonstrate the limitations of SMS services in relationship to contraceptive behaviors, reinforcing the need to connect mHealth to clinic services.

mHealth communication to strengthen postnatal care in rural areas: a systematic review

Background

Postnatal care (PNC) in rural areas is characterised by low uptake, with possible effect on maternal and neonatal mortality rates. Mobile health (mHealth) communication has been proposed to promote the uptake of health services; however, there is limited information on how mHealth can strengthen PNC in rural areas. The objective of this review was to gather the best available evidence regarding mHealth communication to strengthen PNC in rural areas.

Methods

Studies published between 1 January 2008 and 31 August 2018 were searched in electronic databases hosted by EBSCO Host. Reference list checking and contact with authors were also done. Critical appraisal of the eligible studies was also done.

Results

The results of 11 articles were synthesised to report the determinants of PNC uptake. Determinants were aligned to the Integrative Model of Behaviural Prediction (IMBP). One-way mobile phone messaging was the most common type of mHealth communication used. mHealth communication influenced mothers’ intentions, skills, and environmental constraints associated with uptake of PNC. Intentions were influenced by attitudes, perceived norms and self-efficacy. Positive attitudes, as well as changed attitudes toward PNC practices were observed. Perceived norms that were enhanced were delivery at a health facility with immediate PNC, seeking of reinforcement and professional health support of newborn care practices, and male partner support. Improved self-efficacy was demonstrated by mothers who attended scheduled appointments and they were confident with regard to newborn care practices. Skills for PNC that were improved included cord care, thermal care, appropriate breastfeeding and problem-solving. The environmental constraints faced and which were addressed in the studies included inaccessibility, unavailability and unaffordability of PNC services in rural areas.

Conclusions

Results from the literature included in this study show that one-way mobile phone messaging is the common type of mHealth communication used to strengthen PNC in rural areas. mHealth communication can influence intentions, skills and environmental constraints as determinants of PNC uptake. mHealth communication is recommended to strengthen PNC in rural areas. To widen the evidence, more studies in the field of mHealth communication that report a variety of both maternal and neonatal outcomes are needed.

Factors Influencing Unintended Pregnancies amongst Adolescent Girls and Young Women in Cambodia

Background: Unintended pregnancies in Cambodian youth are a major reproductive health concern with detrimental personal and socioeconomic consequences. A social ecological model was used to identify sociodemographic factors potentially associated with unintended pregnancies, and an analysis of data from the 2014 Cambodian Demographic and Health Survey was used to determine associations. Methods: Weighted data were analysed using multiple logistic regression analyses for 3406 Cambodian sexually active single, in union or married females aged 15–29 years. Results: The prevalence of unintended pregnancy was 12.3%. Unintended pregnancy was significantly associated with younger age groups (15–24 years), multiparity, history of abortion, and current use of modern contraceptive methods. All women had an increased likelihood of unintended pregnancy when the husband alone or someone else in the household made decisions about their access to healthcare. Conclusion: The burden of unintended pregnancies is associated with young age, multiparity, history of abortions, unemployment, and low autonomy for accessing healthcare. Multi-pronged, holistic reproductive and sexual health program interventions are needed to increase literacy and accessibility to modern contraception and to raise awareness about women’s health and status in Cambodia.

Clients' perceptions and experiences of targeted digital communication accessible via mobile devices for reproductive, maternal, newborn, child, and adolescent health: a qualitative evidence synthesis

BACKGROUND

Governments and health systems are increasingly using mobile devices to communicate with patients and the public. Targeted digital client communication is when the health system transmits information to particular individuals or groups of people, based on their health or demographic status. Common types of targeted client communication are text messages that remind people to go to appointments or take their medicines. Other types include phone calls, interactive voice response, or multimedia messages that offer healthcare information, advice, monitoring, and support.

OBJECTIVES

To explore clients' perceptions and experiences of targeted digital communication via mobile devices on topics related to reproductive, maternal, newborn, child, or adolescent health (RMNCAH).

SEARCH METHODS

We searched MEDLINE (OvidSP), MEDLINE In-Process & Other Non-Indexed Citations (OvidSP), Embase (Ovid), World Health Organization Global Health Library, and POPLINE databases for eligible studies from inception to 3-6 July 2017 dependant on the database (See appendix 2).

SELECTION CRITERIA

We included studies that used qualitative methods for data collection and analysis; that explored clinets' perceptions and experiences of targeted digital communication via mobile device in the areas of RMNCAH; and were from any setting globally.

DATA COLLECTION AND ANALYSIS

We used maximum variation purposive sampling for data synthesis, employing a three-step sampling frame. We conducted a framework thematic analysis using the Supporting the Use of Research Evidence (SURE) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether potential implementation barriers identified in our synthesis had been addressed in the trials included in the related Cochrane Reviews of effectiveness.

MAIN RESULTS

We included 35 studies, from a wide range of countries on six continents. Nineteen studies were conducted in low- and middle-income settings and sixteen in high-income settings. Some of the studies explored the views of people who had experienced the interventions, whereas others were hypothetical in nature, asking what people felt they would like from a digital health intervention. The studies covered a range of digital targeted client communication, for example medication or appointment reminders, prenatal health information, support for smoking cessation while pregnant, or general sexual health information.Our synthesis showed that clients' experiences of these types of programmes were mixed. Some felt that these programmes provided them with feelings of support and connectedness, as they felt that someone was taking the time to send them messages (moderate confidence in the evidence). They also described sharing the messages with their friends and family (moderate confidence).However, clients also pointed to problems when using these programmes. Some clients had poor access to cell networks and to the internet (high confidence). Others had no phone, had lost or broken their phone, could not afford airtime, or had changed their phone number (moderate confidence). Some clients, particularly women and teenagers, had their access to phones controlled by others (moderate confidence). The cost of messages could also be a problem, and many thought that messages should be free of charge (high confidence). Language issues as well as skills in reading, writing, and using mobile phones could also be a problem (moderate confidence).Clients dealing with stigmatised or personal health conditions such as HIV, family planning, or abortion care were also concerned about privacy and confidentiality (high confidence). Some clients suggested strategies to deal with these issues, such as using neutral language and tailoring the content, timing, and frequency of messages (high confidence).Clients wanted messages at a time and frequency that was convenient for them (moderate confidence). They had preferences for different delivery channels (e.g. short message service (SMS) or interactive voice response) (moderate confidence). They also had preferences about message content, including new knowledge, reminders, solutions, and suggestions about health issues (moderate confidence). Clients' views about who sent the digital health communication could influence their views of the programme (moderate confidence).For an overview of the findings and our confidence in the evidence, please see the 'Summary of qualitative findings' tables.Our matrix shows that many of the trials assessing these types of programmes did not try to address the problems we identified, although this may have been a reporting issue.

AUTHORS' CONCLUSIONS

Our synthesis identified several factors that can influence the successful implementation of targeted client communication programmes using mobile devices. These include barriers to use that have equity implications. Programme planners should take these factors into account when designing and implementing programmes. Future trial authors also need to actively address these factors and to report their efforts in their trial publications.

Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care (The FACTS Study Phase II) After Surgical Abortion: User-Centered Design

Background

Human-centered design is a methodology that applies an iterative participatory process that engages the end-user for whom an innovation or intervention is designed for from start to end. There is general evidence to support the use of human-centered design for development of tools to affect health behavior, but specifically for family planning provision. This study is part two of a three-phase study that uses a user-centered design methodology which uses the findings from Phase I to design, develop, and test a digital health solution to support follow-up after an induced surgical abortion.

Objective

The objectives for this study were to: (1) develop a Web-based intervention based on preferences and experiences of women who underwent an abortion as measured in the formative phase of the Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care Study; (2) conduct usability testing of the intervention to determine user-friendliness and appropriateness of the intervention; and (3) finalize a beta version of the Web-based intervention for pilot testing.

Methods

The study design was based on the “development-evaluation-implementation” process from the Medical Research Council Framework for Complex Medical Interventions. This study is in Phase II of III and is based on user-centered design methodology. Phase I findings demonstrated that women engage with technology to assist in clinical care and they preferred a comprehensive website with email or text notifications to support follow-up care. In Phase II we collaborated with family planning experts and key stakeholders to synthesize evidence from Phase I. With them and a development partner we built a prototype. Usability testing was completed with 9 participants using a validated System Usability Scale. This was then used to refine the intervention for Phase III pilot study. This study was approved by the local Ethics board.

Results

We developed a comprehensive Web-based tool called myPostCare.ca, which includes: Post-Procedure Care, Emotional Well-Being Tool, Contraception Explorer, Sexual Health, Book an Appointment, and Other Resources. Additionally, over the course of a month after the procedure, automatic email notifications were sent to women as a form of virtual follow-up support, directing them to myPostCare.ca resources. The Web-based tool was refined based on usability testing results.

Conclusions

This study demonstrated that user-centered design is a useful methodology to build programs and interventions that are women-centered, specifically for abortion care.

Unintended Consequences of mHealth Interactive Voice Messages Promoting Contraceptive Use After Menstrual Regulation in Bangladesh: Intimate Partner Violence Results From a Randomized Controlled Trial

BACKGROUND

Mobile phones for health (mHealth) hold promise for delivering behavioral interventions. We evaluated the effect of automated interactive voice messages promoting contraceptive use with a focus on long-acting reversible contraceptives (LARCs) among women in Bangladesh who had undergone menstrual regulation (MR), a procedure to "regulate the menstrual cycle when menstruation is absent for a short duration."

METHODS

We recruited MR clients from 41 public- and private-sector clinics immediately after MR. Eligibility criteria included having a personal mobile phone and consenting to receive messages about family planning by phone. We randomized participants remotely to an intervention group that received at least 11 voice messages about contraception over 4 months or to a control group (no messages). The primary outcome was LARC use at 4 months. Adverse events measured included experience of intimate partner violence (IPV). Researchers recruiting participants and 1 analyst were blinded to allocation groups. All analyses were intention to treat. The trial is registered with ClinicalTrials.gov (NCT02579785).

RESULTS

Between December 2015 and March 2016, 485 women were allocated to the intervention group and 484 to the control group. We completed follow-up on 389 intervention and 383 control participants. Forty-eight (12%) participants in the intervention group and 59 (15%) in the control group reported using a LARC method at 4 months (adjusted odds ratio [aOR] using multiple imputation=0.95; 95% confidence interval [CI]=0.49 to 1.83; P=.22). Reported physical IPV was higher in the intervention group: 42 (11%) intervention versus 25 (7%) control (aOR=1.97; 95% CI=1.12 to 3.46; P=.03) when measured using a closed question naming acts of violence. No violence was reported in response to an open question about effects of being in the study.

CONCLUSIONS

The intervention did not increase LARC use but had an unintended consequence of increasing self-reported IPV. Researchers and health program designers should consider possible negative impacts when designing and evaluating mHealth and other reproductive health interventions. IPV must be measured using closed questions naming acts of violence.

A systematic review and meta-analysis in the effectiveness of mobile phone interventions used to improve adherence to antiretroviral therapy in HIV infection

BACKGROUND

Antiretroviral therapy is effective in preventing the progression of HIV to AIDS, but adherence to HIV medication is lower than ideal. A previous Cochrane review concluded that SMS interventions increased adherence to HIV medication, but more recent trials have reported mixed results. Our review aims to provide an up-to-date synthesis of the effects of interventions delivered by mobile phone on adherence.

METHODS

We searched Cochrane, Medline, CINAHL, EMBASE and Global Health for randomised control trials (RCTs) of interventions delivered by mobile phones, designed to increase adherence to antiretroviral medication. Risk of bias was assessed using the Cochrane risk of bias tool. We calculated relative risk ratios (RR) or standardised mean difference (SMD) with 95% confidence interval (CI). Trials were analysed depending on delivery mechanism and intervention characteristics. We conducted meta-analysis for primary objective outcome measures.

RESULTS

We identified 19 trials. No trials were at low risk of bias. Interventions were delivered as follows; nine via text message, five via mobile phone call, one via mobile phone imagery and four via mixed interventions. There was no effect when interventions delivered by text message were pooled in the RR1.25 (CI 0.97 to 1.61) P = 0.08. The SMD 0.42 (0.03 to 0.81) p = 0.04 showed a moderate effect to improve adherence. There was mixed evidence of the effect of text messages delivered daily, weekly, at scheduled or triggered times, however, messages with link to support, interactivity and three or more behavior change techniques (BCTs) all improved adherence. Of the five trials delivered by mobile phone call, one reported a reduction in HIV viral load. One trial using mobile phone imagery reported a reduction in HIV viral load. Three trials that delivered interventions by text message and mobile phone counselling reported improved biological outcomes.

CONCLUSION

Specific interventions, of proven effectiveness should be considered for implementation, rather than mobile phone-based interventions in general. Interventions targeting a wider range of barriers to adherence may be more effective than existing interventions. The effects and cost-effectiveness of such interventions should be evaluated in a randomised controlled trial alongside long term objective and clinically important outcomes.

Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care in British Columbia: Phase I

Background

Over 30% of women in Canada undergo an abortion. Despite the prevalence of the procedure, stigma surrounding abortion in Canada leads to barriers for women to access this service. The vast majority of care is concentrated in urban settings. There is evidence to support utilization of innovative mobile and other technology solutions to empower women to safely and effectively self-manage aspects of the abortion process. This study is part 1 of a 3-phase study that utilizes user-centered design methodology to develop a digital health solution to specifically support follow-up after an induced surgical abortion.

Objective

This study aimed to (1) understand how women at 3 surgical abortion clinics in an urban center of British Columbia utilize their mobile phones to access health care information and (2) understand women’s preferences of content and design of an intervention that will support follow-up care after an induced abortion, including contraceptive use.

Methods

The study design was based on development-evaluation-implementation process from Medical Research Council Framework for Complex Medical Interventions. This was a mixed-methods formative study. Women (aged 14-45 years) were recruited from 3 urban abortion facilities in British Columbia who underwent an induced abortion. Adaptation of validated surveys and using the technology acceptance model and theory of reasoned action, a cross-sectional survey was designed. Interview topics included demographic information; type of wireless device used; cell phone usage; acceptable information to include in a mobile intervention to support women’s abortion care; willingness to use a mobile phone to obtain reproductive health information; optimal strategies to use a mobile intervention to support women; understand preferences for health information resources; and design qualities in a mobile intervention important for ease of use, privacy, and security. Responses to questions in the survey were summarized using descriptive statistics. Qualitative analysis was conducted with NVivo using a thematic analysis approach. This study was approved by the local ethics board.

Results

A waiting-room survey was completed by 50 participants, and semistructured interviews were completed with 8 participants. The average age of participants was 26 years. Furthermore, 94% (47/50) owned a smartphone, 85% (41/48) used their personal phones to go online, and 85% would use their cell phone to assist in clinical care. Qualitative analysis demonstrated that women prefer a comprehensive website that included secure email or text notifications to provide tools and resources for emotional well-being, contraceptive decision making, general sexual health, and postprocedure care.

Conclusions

A community-based mixed-methods approach allowed us to understand how women use their cell phones and what women desire in a mobile intervention to support their postabortion care. The findings from this formative phase will assist in the development and testing of a mobile intervention to support follow-up care after an induced surgical abortion.

Characteristics and contraceptive outcomes of women seeking medical or surgical abortion in reproductive health clinics in Cambodia

Background

Since the approval of medical abortion in Cambodia in 2010, the proportion of women reporting an abortion has increased. We describe the characteristics and contraceptive outcomes of women seeking medical abortion compared to surgical abortion at four reproductive health clinics in Cambodia.

Methods

Secondary data analysis using data collected in the MObile Technology for Improved Family Planning (MOTIF) trial, a single blind, randomized trial of a personalized, mobile phone-based intervention designed to support post-abortion family planning in Cambodia. Baseline interviews were conducted after women had received post-abortion family planning counselling at the clinic, and follow-up interviews were conducted at 4 and 12 months. We used multivariable logistic regression to assess associations between abortion type and baseline characteristics, contraceptive uptake, repeat pregnancy and repeat abortion. We conducted an exploratory analysis to compare the timing of initiation of long-acting (LA) contraception between women having medical versus surgical abortion over the four-month post-abortion period.

Results

Of the 500 women who participated in the trial, 41% had a medical abortion. In multivariate analyses, women undergoing medical abortion were more likely to be urban residents, have a higher level of education, be undecided or not intending to use family planning, and be undecided or intending to have another child. There was no association between type of abortion and contraceptive uptake, repeat pregnancy or repeat abortion. Women who had medical abortion initiated LA contraception post abortion later than women who had surgical abortion.

Conclusions

Our results suggest women having a medical abortion in Cambodia have different baseline characteristics and had delayed uptake of contraception compared to women having a surgical abortion. However, we cannot draw conclusions on the direction of associations and causality. Further research is recommended to explore reasons for the observed findings with view to increasing access to abortion and post-abortion contraception.

m-Health in Public Health Practice

Beyond the earlier skepticism that greeted its usefulness and applicability in public health practice, m-Health has continued to gain significant support and acceptability among public health practitioners in terms of the ease with which its features and reach have been harnessed to address global disease prevention and health promotion objectives. Research evidence over the past few decades suggest the positive effect of adopting m-Health in improving knowledge dissemination, creating and sustaining motivation for positive health behavior changes or practices, and empowering individuals, communities and populations to take greater responsibility for their health. This chapter examines historical and current literature evidence of m-Health application in public health practice, its impact on global population health and future prospects.

Using participatory methods to build an mHealth intervention for female entertainment workers in Cambodia: the development of the Mobile Link project

BACKGROUND

The HIV epidemic in Cambodia is strongly and disproportionately concentrated among key populations. One important hard-to-reach key population is the expanding community of female entertainment workers (FEWs). HIV as well as other sexual and reproductive health (SRH) outcomes including sexually transmitted infections (STIs), contraception, and gynecologic health are also substandard among FEWs. To address these concerns, a mobile health intervention (mHealth) using short message service (SMS) and voice message (VM) services-the Mobile Link project-was constructed. This paper aims to describe the development of this mHealth intervention that used participatory methodologies and to illustrate how these findings can be useful in future mHealth projects.

METHODS

This intervention development process used an iterative, participatory approach. Twenty-seven focus group discussions (FGDs) covering SRH topics were designed and conducted and implemented across four provinces in Cambodia. Additionally, six in-depth interviews (IDIs) were conducted with FEWs living with HIV in Siem Reap and Phnom Penh. Data from the FGDs and IDIs were analyzed using content and matrix analysis methods to identify prioritized themes for messages. Two data validation workshops were organized to present the prioritized themes to FEWs and outreach workers (outreach workers) for validation. The workshops included activities stimulating participation such as listening to sample messages in order to determine health priorities as well as message tone and style.

RESULTS

The findings from the qualitative research provided guidance on how to tailor the intervention to the FEW community in terms of the tone, timing, content and delivery mode of the messages. Participants preferred a friendly, professional female voice for VM. Participants revealed that health priorities such as gynecologic issues (vaginal infections/irritation) and cervical and breast cancer, were emphasized more than HIV and family planning. Participants also reported a number of misconceptions about contraception, particularly around oral contraceptives and intrauterine devices, and STI transmission. Participants expressed the need to build trust in outreach workers and linkages, affirming the emphasis on the link within the Mobile Link project. Lastly, from the IDIs, FEWs living with HIV highlighted wanting supportive/messages to address depressive feelings that may stem from their perceived stigma.

CONCLUSIONS

Utilizing participatory methodologies was demonstrated to be useful in intervention content creation and program implementation. As a result of this intervention development process, the research team gleaned lessons that may be applicable to future mHealth projects including the idea of adding some layers of choice to mHealth interventions for further tailoring at the individual level and the importance of human contact and trusting relationship.

Insights From a Text Messaging-Based Sexual and Reproductive Health Information Program in Tanzania (m4RH): Retrospective Analysis

BACKGROUND

Many mobile health (mHealth) interventions have the potential to generate and store vast amounts of system-generated participant interaction data that could provide insight into user engagement, programmatic strengths, and areas that need improvement to maximize efficacy. However, despite the popularity of mHealth interventions, there is little documentation on how to use these data to monitor and improve programming or to evaluate impact.

OBJECTIVE

This study aimed to better understand how users of the Mobile for Reproductive Health (m4RH) mHealth intervention engaged with the program in Tanzania from September 2013 to August 2016.

METHODS

We conducted secondary data analysis of longitudinal data captured by system logs of participant interactions with the m4RH program from 127 districts in Tanzania from September 2013 to August 2016. Data cleaning and analysis was conducted using Stata 13. The data were examined for completeness and "correctness." No missing data was imputed; respondents with missing or incorrect values were dropped from the analyses.

RESULTS

The total population for analysis included 3,673,702 queries among 409,768 unique visitors. New users represented roughly 11.15% (409,768/3,673,702) of all queries. Among all system queries for new users, 46.10% (188,904/409,768) users accessed the m4RH main menu. Among these users, 89.58% (169,218/188,904) accessed specific m4RH content on family planning, contraceptive methods, adolescent-specific and youth-specific information, and clinic locations after first accessing the m4RH main menu. The majority of these users (216,422/409,768, 52.82%) requested information on contraceptive methods; fewer users (23,236/409,768, 5.67%) requested information on clinic location. The conversion rate was highest during the first and second years of the program when nearly all users (11,246/11,470, 98.05%, and 33,551/34,830, 96.33%, respectively) who accessed m4RH continued on to query more specific content from the system. The rate of users that accessed m4RH and became active users declined slightly from 98.05% (11,246/11,470) in 2013 to 87.54% (56,696/64,765) in 2016. Overall, slightly more than one-third of all new users accessing m4RH sent queries at least once per month for 2 or more months, and 67.86% (278,088/409,768) of new and returning users requested information multiple times per month. Promotional periods were present for 15 of 36 months during the study period.

CONCLUSIONS

The analysis of the rich data captured provides a useful framework with which to measure the degree and nature of user engagement utilizing routine system-generated data. It also contributes to knowledge of how users engage with text messaging (short message service)-based health promotion interventions and demonstrates how data generated on user interactions could inform improvements to the design and delivery of a service, thereby enhancing its effectiveness.

Mobile Link - a theory-based messaging intervention for improving sexual and reproductive health of female entertainment workers in Cambodia: study protocol of a randomized controlled trial

BACKGROUND

In Cambodia, HIV prevalence is concentrated in key populations including among female entertainment workers (FEWs) who may engage in direct or indirect sex work. Reaching FEWs with sexual and reproductive health (SRH) services has been difficult because of their hidden and stigmatized nature. Mobile-phone-based interventions may be an effective way to reach this population and connect them with the existing services. This article describes study design and implementation of a randomized controlled trial (RCT) of a mobile health intervention (the Mobile Link) aiming to improve SRH and related outcomes among FEWs in Cambodia.

METHODS

A two-arm RCT will be used to determine the effectiveness of a mobile-phone-based text/voice messaging intervention. The intervention will be developed through a participatory process. Focus group discussions and in-depth interviews have been conducted to inform and tailor behavior change theory-based text and voice messages. During the implementation phase, 600 FEWs will be recruited and randomly assigned into one of the two arms: (1) a control group and (2) a mobile phone message group (either text messages [SMS] or voice messages [VM], a delivery method chosen by participants). Participants in the control group will also receive a weekly monitoring survey, which will provide real-time information to implementing partners to streamline outreach efforts and be able to quickly identify geographic trends. The primary outcome measures will include self-reported HIV and sexually transmitted infections (STI) testing and treatment, condom use, contraceptive use, and gender-based violence (GBV).

DISCUSSION

If the Mobile Link trial is successful, participants will report an increase in condom use, linkages to screening and treatment for HIV and STI, and contraception use as well as a reduction in GBV. This trial is unique in a number of ways. First, the option of participation mode (SMS or VM) allows participants to choose the message medium that best links them to services. Second, this is the first RCT of a mobile-phone-based behavior change intervention using SMS/VMs to support linkage to SRH services in Cambodia. Lastly, we are working with a hidden, hard-to-reach, and dynamic population with which existing methods of outreach have not been fully successful.

TRIAL REGISTRATION

Clinical trials.gov, NCT03117842 . Registered on 31 March 2017.

Developing mHealth Messages to Promote Postmenstrual Regulation Contraceptive Use in Bangladesh: Participatory Interview Study

BACKGROUND

Abortions are restricted in Bangladesh, but menstrual regulation is an approved alternative, defined as a procedure of regulating the menstrual cycle when menstruation is absent for a short duration. Use of contraception after menstrual regulation can reduce subsequent unintended pregnancy, but in Bangladesh, the contraceptive method mix is dominated by short-term methods, which have higher discontinuation and failure rates. Mobile phones are a channel via which menstrual regulation clients could be offered contraceptive support after leaving the clinic.

OBJECTIVE

This study aimed to support the development of a mobile phone intervention to support postmenstrual regulation family planning use in Bangladesh. It explored what family planning information women want to receive after having a menstrual regulation procedure, whether they would like to receive this information via their mobile phone, and if so, what their preferences are for the way in which it is delivered.

METHODS

We conducted participatory interviews with 24 menstrual regulation clients in Dhaka and Sylhet divisions in Bangladesh. Women were recruited from facilities in urban and peri-urban areas, which included public sector clinics supported by Ipas, an international nongovernmental organization (NGO), and NGO clinics run by Marie Stopes. Main themes covered in the interviews were factors affecting the use of contraception, what information and support women want after their menstrual regulation procedure, how respondents would prefer to receive information about contraception, and other key issues for mobile health (mHealth) interventions, such as language and privacy. As part of the in-depth interviews, women were shown and played 6 different messages about contraception on the research assistant's phone, which they were given to operate, and were then asked to give feedback.

RESULTS

Women were open to both receiving messages about family planning methods on their mobile phones and talking to a counselor about family planning methods over the phone after their menstrual regulation. Women most commonly wanted information about the contraceptive method they were currently using and wanted this information to be tailored to their particular needs. Women preferred voice messages to text and liked the interactive voice message format. When asked to repeat and identify the main points of the messages, women demonstrated good understanding of the content. Women did not seem too concerned with privacy or with others reading the messages and welcomed including their husbands in speaking to a counselor.

CONCLUSIONS

This study found that menstrual regulation clients are very interested in receiving information on their phones to support family planning use and wanted more information about the method of contraception they were using. Participatory voicemail was the preferred modality.

Assessing Rates of Inadequate Feeding Practices Among Children 12-24 months: Results from a Cross-Sectional Survey in Myanmar

Objectives To ensure proper nutrition and optimal health outcomes, it is critical that infants are exclusively breastfed (0-6 months) and then receive adequate feeding from 6-23 months (breastfeeding and frequent feedings of complementary foods). Despite policies and guidelines on adequate feeding in Myanmar, past research has found low rates of adequately fed infants 0-11 months and little is known about the adequacy of feeding practices for children 12-23 months. The aim of this study is to understand the feeding practices of children aged 0-24 months in Myanmar and maternal characteristics associated with adequate feeding practices. Methods This study examines the rates of adequately fed infants and young children (0-23 months) in hard-to-reach townships in Myanmar from a cross-sectional, multistage cluster survey. Survey data on nutritional practices were collected from 489 mothers. Data were analyzed using multivariate regressions. Results We found that 41.8 % of infants under 6 months were exclusively breastfed, 63.2 % of those aged 6-11 months were adequately fed, and 10.3 % of 12-23 month-olds were adequately fed. In multivariate regressions we found that antenatal care visits [1-4 visits, AOR = 6.59 (p < 0.01) and >4 visits, AOR = 6.63 (p < 0.05)] was associated with exclusive breastfeeding for under 6 month old infants. Having >4 antenatal care visits [AOR = 9.97 (p < 0.05)] was associated with adequate feeding for 6-11 months old infants. Conclusions Future nutritional interventions and policies should focus on improving messaging about adequate feeding practices, especially for 12-23 months olds.

Using automated voice messages linked to telephone counselling to increase post-menstrual regulation contraceptive uptake and continuation in Bangladesh: study protocol for a randomised controlled trial

Background

Adoption of modern contraceptive methods after menstrual regulation (MR) is thought to reduce subsequent unwanted pregnancy and abortion. Long-acting reversible contraceptives (LARCs) are highly effective at reducing unintended pregnancy, but uptake in Bangladesh is low. Providing information on the most effective methods of contraception increases uptake of more effective methods. This protocol describes a randomised controlled trial of an intervention delivered by mobile phone designed to support post-MR contraceptive use in Bangladesh.

Methods

This is a multi-site single blind individual randomised controlled trial. At least 960 women undergoing MR procedures at selected facilities will be recruited after their procedure by female research assistants. Women will be randomised into the control or intervention group with a 1:1 ratio.

All participants will receive usual clinic care, including contraceptive counselling and the telephone number of a non-toll-free call centre which provides counselling on MR and contraception. During the 4 months after their MR procedure, intervention participants will be sent 11 recorded interactive voice messages to their mobile phone about contraception with a focus on their chosen method and LARCs. Each message allows the participant to connect directly to the call centre. The intervention is free to the user. The control group will receive no messages delivered by mobile phone. All participants will be asked to complete an in-person questionnaire at recruitment and follow-up questionnaires by telephone at 2 weeks, 4 months and 12 months after their MR. The primary outcome for the trial will be self-reported LARC use 4 months post-MR. Secondary outcomes include LARC use at 2 weeks and 12 months post-MR, use of any effective modern contraceptive method at 2 weeks, 4 months and 12 months post-MR, and contraceptive discontinuation, contraceptive method switching, pregnancy, subsequent MR and experience of violence during the 12 month study period.

Discussion

Mobile phones offer a low-cost mechanism for providing individualised support to women with contraception outside of the clinic setting. This study will provide information on the effects of such an intervention among MR clients in Bangladesh.

Trial registration

Trial registered with clinicaltrials.gov Registration number: NCT02579785 Date of registration: 16th October 2015.

Women's views and experiences of a mobile phone-based intervention to support post-abortion contraception in Cambodia

BACKGROUND

The MObile Technology for Improved Family Planning (MOTIF) trial assessed a mobile phone-based intervention comprising voice messages and counsellor support to increase post-abortion contraception at four Marie Stopes International clinics in Cambodia. The aim of this process evaluation was to assess women's views and experiences of receiving the MOTIF intervention, gain insights into the mechanism of action of the intervention and seek recommendations for improvements.

METHODS

We conducted a qualitative study comprising15 semi-structured interviews with women who had received the intervention and undertook a simple thematic analysis.

RESULTS

We identified themes relating to communication via mobile phone, supporting contraception use, broader post-abortion care, interaction with family and friends and suggestions for improvement. The majority of women were positive about the mobile phone-based intervention to support contraception use and reported it to be a convenient way to ask questions or get advice without going to a health centre, although a few women found the voice messages intrusive. The intervention supported contraception use by provision of information, encouragement, reminders to return to clinic, reassurance and advice for problems and had a positive effect on contraceptive uptake and continuation. Women reported a sense of being cared for and received support for additional physical and emotional issues. Most women thought that the duration of the intervention and frequency of messages were acceptable.

CONCLUSIONS

The majority of women were positive about the mobile phone-based intervention which provided support for contraception use as well as additional physical and emotional issues. The study provides some insights into how the intervention might have worked and considers how the intervention could be improved.

Process evaluation of a mobile phone-based intervention to support post-abortion contraception in Cambodia

BACKGROUND

The MObile Technology for Improved Family Planning (MOTIF) trial assessed a mobile phone-based intervention comprising voice messages and counsellor support to increase post-abortion contraception at four Marie Stopes International clinics in Cambodia. The aim of this process evaluation was to assess participants' interaction with the intervention from a service provider perspective.

METHODS

(1) We conducted a descriptive analysis to assess participants' interaction with the intervention. (2) In order to explore how the intervention might work, we assessed associations between interaction with the intervention and contraception use using logistic regression analysis. (3) We undertook a logistic regression analysis to assess associations between baseline socio-demographic factors and ever requesting to speak to a counsellor (pressing '1'), a variable found to be associated with contraception use.

RESULTS

Amongst 249 women that received six interactive voice messages +/- counsellor support for contraception, around half actively requested to speak to a counsellor (pressed '1') and over 90% spoke to a counsellor at some stage. Women who spoke to the counsellor having requested to (by pressing '1') were more than four times as likely to be using effective contraception at four months compared to women who didn't request or speak to the counsellor (Odds Ratio 4.39; 95% CI: 1.15-16.71). There was a small, non-statistically significant increase in contraception use amongst women that spoke to the counsellor without requesting a call. Increased parity, a history of >2 previous induced abortions, lower socio-economic status, and medical abortion (after adjusting for age, socio-economic status and residence) were associated with requesting to speak to a counsellor.

CONCLUSIONS

The interactive message can identify a subgroup of women in whom counselling will be more effective and appears to be equitable in terms of engaging those most in-need. The intervention could be adapted based on the findings of this study.

Understanding potential uptake of a proposed mHealth program to support caregiver home management of childhood illness in a resource-poor setting: a qualitative evaluation

BACKGROUND

Extensive uptake of mobile phones offers an unprecedented opportunity to improve global healthcare delivery, especially among underserved populations. Mobile health (mHealth) has been increasingly recognized as a promising approach to addressing challenges in global maternal-child health and may play an important role in accelerating progress towards improved outcomes. However, more evidence guiding development of mHealth interventions is needed. The current study explores factors that may support or hinder adoption and use of a proposed mHealth intervention to improve caregiver home management of common childhood illnesses in order to shape program development.

METHODS

Elicitation interviews were conducted with a convenience sample of 25 mothers recruited from a larger cluster-randomized survey sample in the Cono Norte region of Arequipa, Peru. Interview data were analyzed in Spanish to preserve important cultural nuances.

RESULTS

Thematic analysis revealed potential facilitators of and barriers to uptake of the proposed mHealth program. Potential facilitators of caregiver participation include opportunity to engage in two-way communication with healthcare providers, development of instrumental and support knowledge to care for sick children, and healthcare challenges faced in a resource-poor community. Potential barriers include preference for in-person healthcare visits, program cost, text messaging abilities, and concern around program legitimacy.

CONCLUSIONS

This study underscores the potential for mHealth to improve global healthcare delivery in the area of maternal-child health. It demonstrates that mHealth interventions can meet the needs of vulnerable populations by offering novel approaches to promoting evidence-based care. This in-depth understanding of factors that may influence participation and use of this proposed mHealth program will help shape development of the intervention in this community.

Mobile phone use among female entertainment workers in Cambodia: an observation study

BACKGROUND

Text or voice messages containing health behavior change content may be an inexpensive, discreet, sustainable and scalable way to reach populations at high risk for HIV. In Cambodia, one of the important high-risk populations is female entertainment workers (FEWs). This ethnographic study aims to explore typical phone use, examining patterns and behaviors that may influence the design of future mHealth interventions.

METHODS

The study consisted of one 8-hour non-participant observation session for 15 randomly sampled FEWs. Observations focused on capturing normal daily use of mobile devices. Observation checklists were populated by observers during the observations and a post-observation survey was conducted. Findings were discussed with Cambodian HIV outreach workers and HIV research fellows and their interpretations are summarized below.

RESULTS

In this ethnographic study, all 15 participants made calls, checked the time and received research-related texts. More than half (n=8) of the participants engaged in texting to a non-research recipient. About half (n=7) went on Facebook (FB) and some (n=5) listened to music and looked at their FB newsfeed. Fewer played a mobile game, posted a photo to FB, went on YouTube, used FB chat/messenger, watched a video on FB, played a game on FB, used FB call/voice chat, looked at their phone's background or used the LINE app. Fewer still shared their phones, left them unattended, added airtime or changed their SIM cards. When participants received a research text message, most did not share the text message with anyone, did not ask for help deciphering the message and did not receive help composing a response. Notable themes from observer notes, HIV outreach workers and researchers include reasons why phone calls were the most frequent mode of communication, examples of how cell phone company text messages are used as a form of behavior change, literacy as a persistent barrier for some FEWs, and FEWs' high interest in receiving health-related messages and less concern about privacy and phone-sharing issues than expected.

CONCLUSIONS

This study suggests texting is a part of normal phone use although not as frequently used as voice calls or Facebook. Despite the less frequent use, FEWs were able to send and receive messages, were interested in health messages and were not overly concerned about privacy issues. Texting and voice messaging may be useful tools for health behavior change within the FEW population in Cambodia.

Effect of a mobile phone-based intervention on post-abortion contraception: a randomized controlled trial in Cambodia

OBJECTIVE

To assess the effect of a mobile phone-based intervention (mHealth) on post-abortion contraception use by women in Cambodia.

METHODS

The Mobile Technology for Improved Family Planning (MOTIF) study involved women who sought safe abortion services at four Marie Stopes International clinics in Cambodia. We randomly allocated 249 women to a mobile phone-based intervention, which comprised six automated, interactive voice messages with counsellor phone support, as required, whereas 251 women were allocated to a control group receiving standard care. The primary outcome was the self-reported use of an effective contraceptive method, 4 and 12 months after an abortion.

FINDINGS

Data on effective contraceptive use were available for 431 (86%) participants at 4 months and 328 (66%) at 12 months. Significantly more women in the intervention than the control group reported effective contraception use at 4 months (64% versus 46%, respectively; relative risk, RR: 1.39; 95% confidence interval, CI: 1.17-1.66) but not at 12 months (50% versus 43%, respectively; RR: 1.16; 95% CI: 0.92-1.47). However, significantly more women in the intervention group reported using a long-acting contraceptive method at both follow-up times. There was no significant difference between the groups in repeat pregnancies or abortions at 4 or 12 months.

CONCLUSION

Adding a mobile phone-based intervention to abortion care services in Cambodia had a short-term effect on the overall use of any effective contraception, while the use of long-acting contraceptive methods lasted throughout the study period.

Mobile phone-based interventions for improving contraception use

BACKGROUND

Contraception provides significant benefits for women's and children's health, yet an estimated 225 million women had an unmet need for modern contraceptive methods in 2014. Interventions delivered by mobile phone have been demonstrated to be effective in other health areas, but their effects on use of contraception have not been established.

OBJECTIVES

To assess the effects of mobile phone-based interventions for improving contraception use.

SEARCH METHODS

We searched for randomised controlled trials (RCTs) of client-provider interventions delivered by mobile phone to improve contraception use compared with standard care or another intervention. We searched the electronic databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Global Health, PsycINFO, POPLINE, Africa-Wide Information and Latin American Caribbean Health Sciences Literature (LILACS) from January 1993 to October 2014, as well as clinical trials registries, online mHealth resources and abstracts from key conferences.

SELECTION CRITERIA

Randomised controlled trials of mobile phone-based interventions to improve any form of contraception use amongst users or potential users of contraception. Outcome measures included uptake of contraception, measures of adherence, pregnancy and abortion.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of studies retrieved using the search strategy and extracted data from the included studies. We calculated the Mantel-Haenszel risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, together with 95% confidence intervals (CIs). Differences in interventions and outcome measures did not permit us to undertake meta-analysis.

MAIN RESULTS

Five RCTs met our inclusion criteria. Three trials aimed to improve adherence to a specific method of contraception amongst existing or new contraception users by comparing automated text message interventions versus standard care. Two trials aimed to improve both uptake and adherence, not limited to one method, in both users and non-users of contraception. No trials were at low risk of bias in all areas assessed.One trial in the USA reported improved self reported oral contraceptive (OC) continuation at six months from an intervention comprising a range of uni-directional and interactive text messages (RR 1.19, 95% CI 1.05 to 1.35). One trial in Cambodia reported increased self reported use of effective contraception at four months post abortion from an intervention comprising automated interactive voice messages and phone counsellor support (RR 1.39, 95% CI 1.17 to 1.66).One feasibility trial in the USA reported a lower mean number of days between scheduled and completed attendance for the first but not subsequent Depo-Provera appointments using clinic records from an intervention comprising reminders and healthy self management text messages (mean difference (MD) -8.60 days, 95% CI -16.74 to -0.46). Simple text message OC reminders had no effect on missed pills as assessed by electronic medication monitoring in a small trial in the USA (MD 0.5 missed pills, 95% CI -1.08 to 2.08). No effect on self reported contraception use was noted amongst isotretinoin users from an intervention that provided health information via two uni-directional text messages and mail (RR 1.26, 95% CI 0.84 to 1.89). One trial assessed potential adverse effects of the intervention and reported no evidence of road traffic accidents or domestic abuse.

AUTHORS' CONCLUSIONS

Our review provides limited evidence that interventions delivered by mobile phone can improve contraception use. Whilst evidence suggests that a series of interactive voice messages and counsellor support can improve post-abortion contraception, and that a mixture of uni-directional and interactive daily educational text messages can improve OC adherence, the cost-effectiveness and long-term effects of these interventions remain unknown. Further high-quality trials are required to robustly establish the effects of interventions delivered by mobile phone to improve contraception use.