An Intervention Delivered by Mobile Phone Instant Messaging to Increase Acceptability and Use of Effective Contraception Among Young Women in Bolivia: Randomized Controlled Trial

Abstract

Background Although the most effective methods of contraception are available in Bolivia, unmet need for contraception among women aged 15 to 19 years is estimated to be 38% (2008), and the adolescent fertility rate is 71 per 1000 women (2016). Mobile phones are a popular mode to deliver health behavior support. We developed a contraceptive behavioral intervention for young Bolivian women delivered by mobile phone and guided by behavioral science. The intervention consists of short instant messages sent through an app over 4 months. Objective This trial aimed to evaluate the effect of the intervention on young Bolivian women’s use of and attitudes toward the effective contraceptive methods available in Bolivia. Methods This was a parallel group, individually randomized superiority trial with a 1:1 allocation ratio. Women were eligible if they were aged 16 to 24 years, owned a personal Android mobile phone, lived in La Paz or El Alto, reported an unmet need for contraception, and could read Spanish. The target sample size was 1310 participants. Participants allocated to the intervention had access to an app with standard family planning information and intervention messages. Participants allocated to the control group had access to the same app and control messages. Coprimary outcomes were use of effective contraception and acceptability of at least one method of effective contraception at 4 months. Secondary outcomes were use of effective contraception during the study, acceptability of the individual methods, service uptake, unintended pregnancy, and abortion. Process outcomes included knowledge, perceived norms, personal agency, and intention. Outcomes were analyzed using logistic and linear regression. We also asked participants about physical violence. Results A total of 640 participants were enrolled, and 67.0% (429) of them contributed follow-up data for the coprimary outcome, the use of effective contraception. There was no evidence that use differed between the groups (33% control vs 37% intervention; adjusted odds ratio [OR] 1.19, 95% CI 0.80 to 1.77; P=.40). There was a borderline significant effect regarding acceptability (63% control vs 72% intervention; adjusted OR 1.49, 95% CI 0.98 to 2.28; P=.06). There were no statistically significant differences in any of the secondary or process outcomes. The intervention dose received was low. In the control group, 2.8% (6/207) reported experiencing physical violence compared with 1.9% (4/202) in the intervention group (Fisher exact test P=.75). Conclusions This trial was unable to provide definitive conclusions regarding the effect of the intervention on use and acceptability of effective contraception because of under recruitment. Although we cannot strongly recommend implementation, the results suggest that it would be safe and may increase the acceptability of effective contraception if the intervention messages were offered alongside the download of the app. Trial Registration ClinicalTrials.gov NCT02905526; https://clinicaltrials.gov/ct2/show/NCT02905526

The effects of text reminders on the use of family planning services: evidence from a randomised controlled trial in urban Mozambique

“…In family planning specifically, a number of published studies evaluate the effects of short message service (SMS) or rapid message interventions, but report only effects on variables such as contraceptive knowledge or attitudes. These evaluations do not measure or do not find any evidence of shifts in behaviours such as contraceptive use 16–20. Accordingly, a broader evidence base is needed 21…”

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“…McCarthy et al implemented a mHealth intervention including a mobile app with standard family planning information and intervention messages in two countries i.e., Bolivia and Palestine. The intervention in both countries did not find any difference in the uptake of contraception, whereas, in Palestine, participants reported at least one method of contraceptive acceptable (adjusted OR 2.34; 95% CI 1.48–3.68) ( 27 , 28 ).…”

“…Mobile health or mHealth intervention such as short message services (SMS), and mobile app are also identified as effective tools to increase SRH knowledge of adolescent girls ( 27 , 28 , 30 , 33 , 35 , 36 , 49 , 59 ), studies reported that mHealth interventions have the potential to engage and increase SRH knowledge of adolescent girls who are at higher risk of poor SRH outcomes, including adolescents with low parental education and support, adolescents with low SRH knowledge, and adolescents with an early sexual debut ( 27 , 28 , 30 , 33 , 35 , 36 , 58 ). Njuguna et al reported that the use of weekly text messages about HIV prevention and reproductive health significantly increased rates of HIV testing among young girls in Kenya ( 33 ).…”

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“…Alternatively, we may have seen no difference between the arms because the intervention was truly not better than SMS-prompted self-learning and/or no intervention at all. Several other RCTs that have attempted to tie adolescent-targeted digital health interventions to SRH knowledge, acceptability or behavioural outcomes have resulted in similarly inconclusive findings,26 37–40 indicating that digital interventions on their own may not be enough to encourage behavioural change. However, while the above reasons would explain the lack of difference between arms, they do not explain why participants in all arms believed significantly fewer myths at endline than they did at baseline.…”