Volume 123, Issue S1 p. e2-e6
Family planning
Open Access

There are some questions you may not ask in a clinic: Providing contraception information to young people in Kenya using SMS

Heather L. Vahdat

Corresponding Author

Heather L. Vahdat

Social and Behavioral Health Sciences, FHI 360 Durham, USA

Corresponding author at: PO Box 13950, Research Triangle Park, Durham, NC 27709, USA. Tel.: + 1 919 544 7040x11528; fax: + 1 919 544 7261.Search for more papers by this author
Kelly L. L'Engle

Kelly L. L'Engle

Social and Behavioral Health Sciences, FHI 360 Durham, USA

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Kate F. Plourde

Kate F. Plourde

Program Sciences, Research Utilization, FHI 360 Durham, USA

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Loice Magaria

Loice Magaria

Clinical Monitoring Unit, FHI 360 Nairobi, Kenya

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Alice Olawo

Alice Olawo

Applied Research Unit, FHI 360 Nairobi, Kenya

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First published: 02 August 2013
Citations: 46
This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Objective

To evaluate the acceptability, information access, and potential behavioral impact of providing contraception information via text message on mobile phones to young people in Kenya.

Methods

Three methods of data collection were implemented during the 17-month pilot period for the Mobile for Reproductive Health (m4RH) program in Kenya: automatic logging of all queries to the m4RH system; demographic and behavior change questions sent via short message service protocol (SMS) to everyone who used m4RH during the pilot period; and telephone interviews with a subset of m4RH users.

Results

During the pilot period, 4817 unique users accessed m4RH in Kenya. Of these, 82% were 29 years of age and younger, and 36% were male. Condom and natural family-planning information was accessed most frequently, although users queried all methods. One in 5 used the m4RH system to locate nearby clinics. Respondents liked the simple language and confidentiality of receiving health information via mobile phone, and reported increased contraceptive knowledge and use after using m4RH.

Conclusion

Providing contraception information via mobile phone is an effective strategy for reaching young people. More research is needed to learn how to link young people to youth-friendly services effectively.

1 Introduction

Although total fertility rates have steadily decreased over the past 10 years, contraception continues to be a critical public-health issue across Africa [1]. With a total fertility rate of 4.7 in 2010 [2] and a median age of first intercourse of 18.2 years [3], ensuring access to contraception information and services for young people in Kenya is critical. However, traditional clinic-based approaches may be insufficient for meeting the reproductive health needs of youth. Only 12% of women and 4% of men aged 15–19 years in Kenya reported receiving contraception information from a health facility or health worker in 2008–2009 [3]. By contrast, 50% of women and 55% of men aged 15–19 years reported hearing about family planning on the radio, with approximately 25% hearing about it through television or newspaper [3]. Evidence shows that mass media is effective for encouraging use of contraception [4,5], and mass media interventions may effectively reach young people with contraception information.

When considering mass media in Sub-Saharan Africa, it is important to include mobile phones. Mobiles are accessible to younger populations, with subscriptions for people under 30 expected to reach 108 million in 2012 [6,7]. Mobile subscriptions account for 63% of the population of Kenya, where the rural population is 78%. Therefore, it is reasonable to assume that mobile phones will reach individuals in rural areas [8,9]. Use of short message service protocol (SMS, or text messaging) has increased on a global scale, with more than 200 000 text messages sent every second [10]. Several factors make SMS appealing: messages are inexpensive (typically US $0.01–0.05 per message), private, and efficient.

Connecting youth to clinic services is a longstanding concern, and particularly challenging in the context of reproductive health. Barriers to youth accessing clinics for contraception include limited or misinformation; cost and convenience of clinic services; privacy concerns; and provider biases toward sexual activity among young unmarried individuals [11–13]. Mobile phones may address some of these barriers; while there is 1 doctor for every 10 000 Kenyans [14], there are approximately 6200 mobile phone subscriptions per 10 000 people [8].

The aims of the present study were to investigate young people's use of Mobile for Reproductive Health (m4RH), a text message-based contraception information service. We investigated 3 questions related to use of the m4RH system. Is m4RH an acceptable means of providing contraception information to young people? What types of information do young people learn about from m4RH? How does using m4RH influence young people's contraceptive behavior?

2 Materials and methods

Mobile for Reproductive Health is an automated, on-demand SMS system that provides basic messages about 9 different contraceptive methods, ranging from short-acting to permanent. When an m4RH user sends a code via SMS (e.g. “11” for contraceptive implants), the system automatically responds with information about the selected method. Information is presented in a concise format of 2–3 messages per method. Messages were developed using global guidance from WHO [15] and local agencies [16] to communicate essential facts and address common misconceptions. Messages are sent only upon user request. The program also provides a searchable database for users to locate clinics. During its 17-month pilot period, from January 2010 to June 2011, 4817 unique users accessed m4RH, which was provided for free and promoted in a small number of Marie Stopes Kenya and Family Health Options of Kenya partner clinics, and in a radio campaign promoting family planning to young people (Fig. 1).

Details are in the caption following the image

Mobile for Reproductive Health (m4RH) promotional poster and palm cards.

2.1 Data collection

Three methods of data collection were used to evaluate the acceptability, information access, and potential impact of providing contraception information via SMS to young people in Kenya: automatic logging of all m4RH system queries; demographic and behavior change questions sent via SMS to all users who accessed m4RH during the pilot period; and in-depth telephone interviews with a subset of m4RH users. Ethics approval was obtained from Kenya Medical Research Institute and the FHI 360 Protection of Human Subjects Committee.

2.1.1 m4RH system queries

System logs automatically captured basic data for each query to the m4RH system, including mobile number, information queried (e.g. contraceptive method type), and date and time of the query.

2.1.2 SMS questions

Every m4RH user who accessed the system was later sent 3 questions via SMS. The first was: “Please tell us your gender. Reply F if you are female, M if you are male.” The second was: “Which is true for you? If you are 19 or younger reply A; If 20–29 reply B; If 30–39 reply C; If 40 or older reply D.” The third question was open-ended: “How has m4RH changed your use of family planning? Reply CHANGE then your change, like ‘CHANGE got an IUD’.”

Questions were sent in batches, with an average of 9 months (range, 3–18 months) between the user's initial query and receipt of the SMS questions. The variation in follow-up times was due to data collection not being initiated until 12 months after system launch. An introductory text message providing the essential elements of informed consent was sent to each user prior to sending the 3 questions.

System log data and responses to the SMS questions were merged into a database and matched by mobile phone number.

2.1.3 In-depth telephone interviews

Users who answered SMS questions about gender and age were sent an SMS request to participate in a telephone interview. Users who answered affirmatively were contacted and interviewed based on their availability. Twenty-six interviews were conducted by trained research associates based in Nairobi in August, September, and December 2011, with a convenience sample of respondents. Most interviews were conducted in English, although some were conducted in Swahili. Verbal informed consent was obtained from all participants.

Interviews lasted an average of 30 minutes, and participants received air time as an incentive for participation. The structured interview guide covered reasons for using m4RH, message comprehension, use of contraception and services, and changes in contraceptive knowledge and behavior after using m4RH. Through a standard iterative process [17], a codebook was developed and used to structurally and thematically code the transcripts using QSR NVivo version 8 (QSR International, Doncaster, Victoria, Australia). Code reports and summaries were generated and analyzed to address study objectives.

3 Results

Of the 4817 m4RH users during the pilot period, approximately 24% (n = 1161) responded with their age. Of these, 82% (n = 950) were 29 years or younger; 22% were 19 or younger; and 60% were 20–29 years (Table 1). Approximately 22% (n = 1062) of m4RH users answered the gender question; of these, 61% (n = 650) were female. Among users 29 and younger, 83% (n = 792) reported their gender; more than one-third (36%; n = 294) of younger respondents were male. Approximately half (48%; n = 457) of the younger respondents answered the open-ended change question.

Table 1. Responses from m4RH users to age and sex questions answered via short message service protocol.
No. %
Age, y
 ≤ 19 257 22.1
 20–29 693 59.7
 30–39 151 13.0
 ≥ 40 60 5.2
 Total 1161 100.0
Sex
 Female 650 61.2
 Male 412 38.8
 Total 1062 100.0
  • Abbreviation: m4RH, Mobile for Reproductive Health.

Of the 26 telephone interviews, 22 involved participants aged 18–24 years. Youth participants were mostly unmarried (n = 16), with approximately half living in urban areas (n = 10). Half of the youth respondents (n = 11) had some secondary education and the remainder had attended college. Among the youth respondents, 15 were female and 7 were male. The large proportion of youth respondents among all telephone interview participants allowed for tailored analysis of data from this subgroup.

Results include quantitative and qualitative data highlighting the acceptability, information access, and potential impact of using mobile phones to provide contraceptive information to young people in Kenya, outside of the clinic setting. Table 2 presents user quotations supporting these aspects of m4RH.

Table 2. User quotes supporting acceptability, information access, and potential impact of the m4RH system.
Concept User quote
Acceptability
Confidentiality “I like [m4RH] a lot! It is time saving—only you and your phone, and [it's] confidential—only you and your phone!” (Male, 21).
“There is privacy available, many people have mobile phones, you do not have to be seen going to the clinic” (Female, 20).
“There are some questions you may not ask in a clinic or may be difficult or you may feel shy when asking” (Female, 23).
“I learnt a lot [from m4RH]. I got the type of information you can only get from a clinic and sometimes you shy off from going to clinics because it's personal” (Male, 21).
Language “It is using terms you can understand. It has clear knowledge on what you want to know. It is simple to understand, simple language that everyone can understand” (Female, 22).
“I like the advice provided on family planning and the way clients are handled – there is no bad language used” (Female, 20).
Information access
Learning about contraception “I learned about different methods of FP, the ones I did not know existed […] I did not know other FP methods like implants existed” (Female, 22).
“I am able to raise only two children. I will not have any more because of m4RH, that is, after the advice from m4RH” (Male, 19).
Dual protection “I learned condoms prevent pregnancy and sexually transmitted infections” (Female, 22).
“I decided to continue using condoms because it has a dual protection against STI and pregnancy” (Male, 21).
Potential impact
Contraceptive methods “I would have sex without a condom before using m4RH…it [m4RH] has helped me. I would have sex without CD [condom] hence I was exposed to STIs, HIV and pregnancy on the part of my girlfriend but I cannot have sex without condoms after m4RH” (Male, 20).
“I settled on using a condom because I did not want to go to a health center for any other FP method” (Female, 22).
“No, I did not do anything because I am still single, but, when time comes I will know what to do” (Female, 23).
“Not really, I did not change my method, I just continued with it; I am using injections” (Female, 23).
Clinic use “I started using the everyday pill. After m4RH I visited the clinic and got pills, now I have no fear of getting pregnant” (Female, 21).
“I went to the clinic to ask about FP methods I can use other than injection for my partner” (Male, 24).
  • Abbreviations: FP, family planning; m4RH, Mobile for Reproductive Health; STI, sexually transmitted infection.

3.1 Acceptability

Young people, defined in the present study as those who were 29 years of age or younger, liked the convenience of m4RH, noting that it was both fast and free. Most telephone respondents reported that the platform was easy to use and simple, and appreciated the ability to obtain health information via mobile phone. Young users frequently commented on the confidentiality of m4RH. The majority of telephone respondents seemed to like m4RH content, reporting that messages were easy to understand and informative. Many participants reported appreciating the tone of the messages and stated that the messages were friendly and non-judgmental.

Although telephone respondents were not directly asked their opinions about health services, they commonly reported barriers to clinic attendance, including high cost, lack of time, and lack of Confidentiality. Many participants reported being uncomfortable visiting a clinic owing to perceived provider bias and fear of judgment. m4RH was reported as particularly relevant and helpful to younger users in addressing this issue. Since m4RH is free, confidential, and convenient, participants seemed to feel that it was a valuable source of contraception information outside of the clinic setting.

3.2 Information access

Young m4RH users who reported their age via SMS accessed information about a range of contraceptive methods. Condoms and natural family planning were most frequently accessed, with approximately 30% of younger users querying these methods (Table 3). Approximately one in five younger users queried the clinic database, indicating potential interest in learning locations of nearby clinics. The youngest m4RH users queried 2.3 different contraceptive methods on average, while 20–29-year-old m4RH users queried 2.8 different contraceptive methods on average.

Table 3. Proportion of younger users accessing contraceptive method information and clinic locations via m4RH.
Total
(n = 1155)
19 and younger
(n = 257)
20–29
(n = 688)
No. % No. % No. %
Condoms 343 29.7 72 28.0 216 31.4
Natural family planning 395 34.2 64 24.9 255 37.1
OCPs 261 22.6 55 21.4 165 24.0
Implants 266 23.0 53 20.6 166 24.1
EC 236 20.4 52 20.2 144 20.9
Injectable 243 21.0 47 18.3 155 22.5
IUD 229 19.8 41 16.0 146 21.2
Permanent methods 203 17.6 41 16.0 120 17.4
LAM 127 10.9 32 12.5 71 10.2
Clinic locations 267 23.1 58 22.6 149 21.7
  • Abbreviations: EC, emergency contraception; IUD, intrauterine device; LAM, lactational amenorrhea method; m4RH, Mobile for Reproductive Health; OCP, oral contraceptive pill.

When asked what they learned from m4RH, most respondents reported learning new contraception information. Participants also reported that they better understood the correct use of contraceptive methods because of knowledge gained through m4RH. Many participants stated that m4RH taught them about contraceptive side effects and dual protection. Some younger participants felt their knowledge of pregnancy prevention increased.

3.3 Potential impact

When asked whether accessing m4RH had prompted them to take action with respect to contraception use or visiting health facilities, respondents mentioned changes in contraception use and some reported attending a health facility. Much of the behavior change among young people seemed motivated by a desire to prevent pregnancy. The most common behavior change reported was use of condoms, followed by use of emergency contraception or a calendar method. Young people also reported switching from condoms to oral contraceptive pills, or starting oral contraceptive pills. Some young people mentioned attending a clinic after using m4RH. Others chose contraception that did not have to be acquired in clinic settings.

The most common reason young people reported not using contraception was because they were single. Single youths reported not using contraceptives because they were not sexually active or because they felt contraception was only for people who have families. These respondents said they accessed m4RH to obtain information for future action. Other young people who did not change their behavior reported continuing with their current method, suggesting that m4RH may support contraceptive continuation.

Responses to the SMS question “How has m4RH affected your use of family planning?” provide additional insights into how m4RH may influence young people's contraceptive knowledge and behavior. The types of change and examples of responses reported via SMS are provided in Table 4. Of the 457 responses reported by younger m4RH users, the most common contraceptives mentioned were condoms (n = 82) and intrauterine device (IUD; n = 67), followed by pills including daily and emergency pills (n = 59) and injectables (n = 46). Natural family planning (n = 30) and implants (n = 30) were also mentioned by a number of younger respondents. General changes were reported by many respondents (n = 103), including references to family-planning discussions, benefits of child spacing, and increases in contraception knowledge.

Table 4. Self-reported changes in contraceptive use following access to m4RH system (reported via text message).
Method Total (n = 457) ≤ 19 y (n = 103) 20–29 y (n = 354) Sample responses
Condoms 82 16 66 “I use a new condom every time;” “Now use condoms because they don't have side effects and protect against STIs”
IUD 67 22 45 “I've got an IUD so I don't have to take pills everyday which many times I used to forget;” “Got an IUCD”
Pills 59 13 46 “Use pills and condoms instead of condoms alone;” “I use epills on emergency cases only”
Injectable 46 6 40 “My fiancée got an injection;” “Got an injection which works well for me”
Implants 30 6 24 “I got an implant;” “Got Jadelle”
Natural family planning 30 3 27 “Got to know that pregnancy occurs between 8–19 if cycles are about a month apart I use it and it is good for me”
Permanent methods 2 1 1 “Had tubal ligation”
General change 103 26 77 “We now talk about sex and contraceptive;” “It has really helped in child birth control and better financial planning”
No change 15 5 10 “Still on condoms;” “Single”
Other 23 5 18 “Decided to abstain from unprotected sex;” “To know the location of clinic”
  • Abbreviations: IUCD, intrauterine contraceptive device; IUD, intrauterine device; m4RH, Mobile for Reproductive Health; STI, sexually transmitted infection.

4 Discussion

The m4RH system builds on earlier programs that used SMS to reach targeted audiences with health information [18,19]. Mobile for Reproductive Health is the first program to focus on contraception in Sub-Saharan Africa; the automated and interactive features of the program and the searchable database of clinic locations add to its innovative nature. Given the lack of evidence about reach and impact of mobile phone programs focused on health objectives [20], the data from the present study may help health professionals and program implementers to assess the utility of reaching young people via mobile phone.

In line with previous successes in promoting reproductive health behaviors using mass media [4,5], mobile phones appear to be a feasible option for reaching young people with information about contraception. Mobile phones provide an additional means for communicating reproductive health information and should be considered as a complement to traditional media channels, particularly for reaching young people. Mobile phone programs may be best conceived and implemented as complements to traditional health programming, and a program like m4RH is a relatively cost-effective approach to encouraging behavior change.

Young m4RH users appreciated that contraception information could be obtained confidentially, conveniently, and for free. By overcoming some logistical and stigma-related barriers to use of contraception [11–13], data from the m4RH pilot demonstrate the potential to increase contraceptive knowledge and behavior change among young people in Kenya. The m4RH program delivers contraception messages in a format that is concise and consistent with clinic-based counseling messages. By providing easy access to information about contraceptive methods and their adverse effects, m4RH has the ability to increase knowledge, uptake, and continuation of contraception among young people.

Although m4RH demonstrates promise for overcoming clinic barriers and reaching young people with contraception information, connecting young people to clinic services remains an important goal. Promoting uptake of provider-dependent, long-acting methods such as IUDs and contraceptive implants has the potential to increase contraception continuation and decrease birth rates, and has been found to be acceptable among young people [21,22]. Further investigations into how to link young people to clinics and youth-friendly services—using mobile phones and other approaches—are needed.

The present study had several limitations. Data were collected during a pilot period when promotion was confined to a small number of clinics and partners. Also, only one-quarter of m4RH users responded to SMS data collection with their age, and only a small number of users were interviewed via telephone; non-responders may have had different characteristics or perspectives on m4RH compared with the results reported in the present manuscript. It is also possible that the delay between initial system access and receipt of SMS follow-up questions contributed to lower response rates. Therefore, the study findings should be interpreted with caution. Nevertheless, the results indicate that a text message-based contraception information system supports the use of mobile phones as a tool for reaching and engaging young people to learn about contraceptive methods.

Acknowledgments

We thank Text to Change, the Kenya Ministry of Public Health and Sanitation and the Division of Reproductive Health, Marie Stopes Kenya, Family Health Options of Kenya, and PSI. The present work was made possible by support from the US Agency for International Development (USAID). The contents are the responsibility of FHI 360 and do not necessarily reflect the views of USAID or the United States Government. Financial assistance was provided by USAID under the terms of Cooperative Agreement GPO-A-00-08-00001-00, the Program Research for Strengthening Services (PROGRESS) Program.

Conflict of interest

The authors have no conflicts of interest.