Implementation of CycleTel Family Advice: an SMS-based service to provide family planning and fertility awareness information in India

Abstract

Background: CycleTel Family Advice (CFA), an SMS-based service designed to improve knowledge of fertility and family planning (FP), was delivered to over 100,000 people in India from April to August 2015.The goal of CFA was to increase knowledge on a range of reproductive health topics, e.g., the menstrual cycle, fertility, and FP, and to increase positive perceptions and use of FP. This paper focuses on the best practices and operational challenges for providing an SMS service based on the implementation experience of CFA. Methods:The implementation process for CFA was well documented, specifically program design, commercial partnerships, formative research, design of messages, and recruitment of users. The impact of CFA on knowledge, attitudes, and behaviors was assessed through phone surveys before and after message delivery.Results: Programmatic data and phone surveys resulted in several operational findings, particularly in the areas of user behavior, partnership management, and mHealth research. While there were improvements in knowledge, there were not significant changes in FP use and couple communication. Conclusions:The intervention yielded insights into designing an mHealth intervention as well as the opportunities and challenges of implementing a stand-alone SMS-based service with a broad audience.Lessons learned were that (I) SMS-based interventions, without other supporting systems, may not lead to high user engagement or behavior change; (II) partnerships with private sector technical platforms can help overcome the difficult problem of marketing and outreach, but they bring limitations to user interface and dependencies on a commercial structure; (III) collecting demographic data required to provide tailored content may be a barrier to user acquisition; and (IV) while phone surveys are useful for evaluation of mHealth interventions, reaching users is challenging and response rates are low.

A clinic-based tablet application to support safer conception among HIV serodiscordant couples in Kenya: feasibility and acceptability study

“…The majority of mHealth studies in sub-Saharan Africa have used SMS messages for health education, reminder messaging, and data collection; however, these strategies may have minimal effectiveness if they are not well integrated into existing healthcare systems or paired with other health provider and systems-based technologies such as providerfacing mHealth tools or patient-facing smart phone applications (25,30). Although patient-facing phone and tablet applications for fertility tracking exist worldwide, studies have shown low uptake of these tools in settings with low knowledge about fertility indicators and where women report skepticism of the applications' ability to correctly predict ovulation cycles (47).…”

“…In Kenya, several studies have demonstrated the acceptability, feasibility, and effectiveness of SMS messages aimed at increasing rates of HIV testing (18) and ART adherence (19)(20)(21), improving sexual behavior measurement (22,23), and increasing healthcare worker adherence to HIV treatment guidelines (24). mHealth interventions have also been used to deliver information regarding menstrual cycle timing and family planning methods to address health systems challenges related to service availability and efficiency during clinic visits (25)(26)(27)(28)(29). However, these mHealth programs are primarily directed at patients rather than healthcare providers, and none have been developed to specifically support safer conception among HIV serodiscordant couples (30).…”

Use of Fertility Awareness-Based Methods for Pregnancy Prevention Among Ghanaian Women: A Nationally Representative Cross-Sectional Survey

“…Although 2 apps have received clearance from the United States Food and Drug Administration for use as a contraceptive method (Natural Cycles in 2018, 22 which also received CE Marking in Europe, and Clue in 2021 23 ), most such apps or devices are not tested or indicated for this purpose and may offer predictions of unknown accuracy regarding the timing of fertile days. 24,25 Research focused specifically on FABM use in low-and middle-income countries (LMICs) has been particularly limited (with exceptions from the United States Agency for International Development and the Institute for Reproductive Health at Georgetown University 18,[26][27][28][29][30][31] ). However, there are existing and emerging reasons for greater understanding around FABM use in LMICs.…”

Market-testing a smartphone application for family planning: assessing potential of the CycleBeads app in seven countries through digital monitoring

“…SDM is recognized as a modern method of family planning by the United States Agency for International Development (USAID) (4) and the World Health Organization (5), and has an efficacy rate of 95% with perfect use and 88% for typical use, similar to other userinitiated methods (6). Extensive studies have been conducted on the SDM with the physical CycleBeads product, and it has been found to be a low-cost, highly acceptable family planning method (6,7). Research on the initial use and acceptability of the CycleBeads app as a digital platform for using SDM in Kenya found that the app was understood and used correctly by women who downloaded it, and social media (specifically Facebook advertising) was found to be a low-cost way of reaching potential users (7).…”

“…Extensive studies have been conducted on the SDM with the physical CycleBeads product, and it has been found to be a low-cost, highly acceptable family planning method (6,7). Research on the initial use and acceptability of the CycleBeads app as a digital platform for using SDM in Kenya found that the app was understood and used correctly by women who downloaded it, and social media (specifically Facebook advertising) was found to be a low-cost way of reaching potential users (7).…”