From September 2013 to June 2014, with support from USAID, Pathfinder Internationalimplemented the mCenas! (“Mobile Scenes”) project in Mozambique—an interactive two-way SMS system, accessible at no cost to clients. The goal of mCenas! was to reduce the barriers youth face in starting or continuing to use contraception by increasing their knowledge of and dispelling common myths about contraceptive methods.

mCenas! engaged young people aged 15-24 with an SMS-based role model story, in which characters were shown overcoming common barriers to contraceptive use faced by youth. For more information on sexual and reproductive health, youth could also access a menu-based message system on their phone and were prompted to call a Ministry of Health- supported hotline, where live operators were poised to answer their questions.

The project, which ran from September 2013 through June 2014 in Maputo and Inhambane provinces, saw 2,000 young people make more than 17,000 requests for information.

Timeline

Inquire

Analysis of surveys in Mozambique presented the program team with the following baseline statistics

• Contraception rates had been steady during last 10 years
• Only 8% of women between 15 and 19 years old use a modern contraceptive method (15% of the women between 20 to 24 years old)
• Unmet need for contraception is 20% in urban areas and 18% in rural areas
• 38% of women between 15 and 19 years old are already mothers or were pregnant at the time of the DHS 2011
• At the age of 15, 5% of the girls have already given birth to a child and by the age of 19, 63% have already given birth to a child
• In Mozambique in 2012, 35 per 100 inhabitants had a mobile cellular subscription (ITU) and 33% of inhabitants had a mobile device

The team identified the need for young people to receive information about contraception and contraceptive services, as well as the need to work with youth to identify strategies to overcome the multiple barriers they face in seeking contraceptive services and using contraception to delay or space pregnancies.

Pathfinder International used its innovative Pathways to Change tool was used to gather information from the target population about the barriers to and facilitators of contraceptive use, and to generate initial story ideas. Fourteen sessions were conducted with demographic subcategories in order to detect differences in the perceptions and experiences by place of residence, age, gender, educational status, and whether or not they had children. One additional follow-up focus group was conducted with a mixed group.

Example of a text message sent through mCenas!Martine is 15 and attends school. She lives with her mother and 4 younger siblings in a small town. She has a boyfriend, Michael, who is also in school. They have not had sex but sometimes when they are alone they would like to. What would make it harder/easier for Martine to go to a health center to get a contraceptive method?

• mCenas! SMS Client Education to Improve Family Planning Uptake Among Youth
• Pathways to Change [Game and Moderator’s Handbook]

Design the Strategy

The team began to design the initiative to not only provide information to youth, foster reflection, and generate strategies to overcome barriers and maximize facilitators for use of contraceptive and other sexual and reproductive health (SRH) services.

With this in mind, they started with one of the cornerstones of Pathfinder’s behavior change approach, which is the use of narrative (or stories) in order to present information in a format that can contextualize and highlight multiple dimensions of behavior. Unlike informational messages, realistically detailed stories permit observational learning and adaption of information to the youths’ own lives and situations. They also talked with experts on mHealth and learned about lessons learned from a range of SMS experiences.

The team developed the following conceptual pillars of the campaign design:

• Youth need information AND strategies to address the entire range of barriers
• The program should build on use of narrative
• The narrative should draw on the experiences of and lessons learned from other SMS and mHealth programs
• The team needs to complement the stories with the following:
  • A way for youth to receive straightforward information on methods
  • A mechanism for interactivity and a way to address sexuality, sexual health, rights, and reproductive health

Create and Test

To create the messages and stories, an experienced Mozambican scriptwriting consultant was involved and she, together with the visiting Pathfinder HQ advisor identified the top two to three barriers and facilitators around which to build the story.

The scriptwriter and the HQ advisor, with input from local staff with community experience, brainstormed storylines around these key barriers and facilitators. This included the development of the story’s “world” (which the team decided would be the same for all stories) as well as the development of the two main female and male characters. The team took care to define a world that would be relevant to both rural and peri-urban youth.

During pretesting, the stories were read to a small group of staff for feedback. This generated excellent discussion and a number of good ideas which were incorporated into the stories. Then the script-writer developed the full storylines, broken into 24 chapters each. These were again reviewed and revised by local staff and an HQ behavior change advisor. From this point on, all content development occurred in Portuguese. Each chapter was then put into SMS form (three 160 character messages per chapter) utilizing local youth texting abbreviations and expressions. Two of the stories in SMS format were pre-tested with the corresponding groups (see photo) for comprehensibility in both provinces.

The team brainstormed a set of message topics around sexuality and questions frequently asked by youth, and a focus group with youth helped the team to choose/add topics of concern. Then the draft messages were shared with the MOH and other stakeholders.

In addition, the team coordinated a link with an existing hotline, part of a JHU CCP project. The Pathfinder team provided additional SRH training to hotline operators and mCenas! users were encouraged to call the number as part of the messaging.

• mCenas! SMS Client Education to Improve Family Planning Uptake Among Youth
• mCenas! The Power of a Story

Mobilize and Monitor

In the first and second months of the campaign, story messages were sent three times each week for eight weeks—one story for youth with children and one story for youth without children. For these two months, young clients followed a compelling and realistic narrative. Youth followed the stories of characters overcoming common barriers to contraceptive use. The use of stories, rather than messages, is one way in which behavior change activities are distinguished from informational dissemination activities. Unlike messages, the realistically detailed stories of mCenas! permit observational learning and help participants adapt information to their own lives and situations.

In the third month, contraceptive method information SMS messages (see photo) went to users three times each week for four weeks. During the entire period, the mCenas! site and mobile app offered a contraceptive method information menu and a list of Frequently Asked Questions (FAQs).

Mobilization also included training of 20 peer educators from two youth community-based organizations in Matola and Inhambane on how to register to receive messages, as well as outreach activities held at secondary schools and in communities. The outreach activities included a door to door campaign, health fairs, and community events. In order to enroll in mCenas!, the individual needed to be between 15-24 years of age, have a cellphone of their own and have minimum skills in using text SMS.

Evaluate and Evolve

Below are some of the key findings from the mCenas! evaluation:

Knowledge about contraception:

• mCenas! contributed to an increase in the number of contraceptive methods the young participants knew about: Medium-high knowledge of three or more contraceptive methods rose from 74.4% of females with children and 59.9% of females without children to 86.6% and 73.9% respectively at endline
• Safety, ease of use, and effectiveness of contraceptive methods: Perceptions of safety, ease of use, and effectiveness improved significantly among both males and females for multiple modern methods between baseline and endline

Contraceptive use:

• Ever use and current use of contraception: The study shows statistically significant inter-survey increases only for combined oral pill and emergency contraception (only among females with children).
• Intention to use a contraceptive method: Intention to use a method was examined separately for respondents who reported to be using a method and those who reported they were not. The interventions contributed to some increases in intention to use a method in the future.

Contraception attitudes, beliefs, and outcome expectations:

• Youth were better informed about contraception and its effects following exposure to the SMS interventions.
• During mCenas! there were significant declines in the percentage of youth who believe that use of contraception will make it difficult to have children after stopping use and significant increases in the percentage of youth who agreed it was okay for a young married/unmarried woman to use other contraceptive methods besides condom.
• Youth who view contraception as a way to increase opportunities for further education increased significantly, though only among those without children.

Perceived self-efficacy:

• While the SMS interventions could be said to have moderately enhanced the confidence of male youth to perform some tasks, the same cannot be said of female youth: the SMS intervention appears to have had no effect on their confidence to perform contraception-related tasks.

Potential barriers to contraceptive use:

• At both baseline and endline, the overwhelming majority of respondents (in most cases more than 8 of 10) agreed with statements that reflect attitudes/conditions that promote contraceptive use and disagreed with statements that reflect attitudes/conditions that hinder contraceptive use.

Acceptability of mCenas!:

• The majority of participants were satisfied with the intervention.
• They felt comfortable sending and receiving SMS messages about SRH and expressed willingness to receive SMS messages on SRH in future.
• They were largely comfortable with the days and times of the week that they received the messages.
• More than half of the respondents said there were just enough messages and that they were satisfied with their length.
• Despite some challenges, including network failure and difficulties in sending messages, more than 90 percent of participants said they would be willing to pay for the same type of messages in the future.

Resource: Assessing the Effects of mCenas! SMS Education on Knowledge, Attitudes, and Self-Efficacy Related to Contraception in Mozambique

Knowledge about Contraception: medium-high knowledge of three or more contraceptive methods

Lesson Learned: Give it Time

Give mobile phone interventions sufficient time. Disseminating contraception messages to youth via SMS has the potential to increase knowledge of contraception, reduce misconceptions, and improve attitudes about contraception among youth. To maximize the benefits of mobile phone interventions, they may need to be implemented over a relatively long period of time to give beneficiaries sufficient time to process and act on the information they receive. It usually takes time to translate knowledge to practice and three months may not be enough.

Lesson Learned: Focus on Safety and Effectiveness

Consider focus on safety and effectiveness of methods. Knowledge, specifically about the safety and effectiveness of contraceptive methods, was low among the youth in this study. In view of the fact that perceptions of the safety and effectiveness of contraceptive methods might inform the decision to use them, subsequent mHealth interventions may consider developing additional content/messages focused on safety and effectiveness of methods, potentially including comparative effectiveness of methods.

Lesson Learned: Address Self-Efficacy

Address self-efficacy among female youth. Self-efficacy about contraception was considerably low among female youth, and, unfortunately, mCenas! did not appear to improve the situation. Subsequent mobile phone interventions should devote significant effort to addressing self-efficacy among female youth by reviewing messages to ensure an emphasis on building confidence to seek and use contraception services, and by complementing mHealth with community activities, such as face-to-face communication with peers and peer educators, which can include role play and coaching. Also, there needs to be better understanding of the reasons for low self-efficacy for contraceptive use among young women, and where gender inequity is implicated, interventions should involve young men.

Lesson Learned: Assessing the Value of mHealth Efforts

Design mHealth studies to permit an assessment of the relative contribution of the mobile phone application to improvements in knowledge, attitudes, and self-efficacy related to contraception. mCenas! was an integrated program (use of mobile phone plus other community- and facility-level activities), making it difficult to assess the relative contribution of the mobile phone application to the observed increase in contraceptive knowledge and improvements in attitudes toward contraception. A design that permits a comparison of an integrated program with a standalone program would have permitted a richer assessment of these elements.

Lesson Learned: Sustainability

Explore how interventions like mCenas! can be implemented and sustained in Mozambique.The overwhelming majority of respondents expressed acceptance of mCenas!, implying that SRH messages delivered through this channel have high probability of reaching youth. As mobile phone ownership increases among youth, mHealth interventions might become an increasingly important channel to address SRH issues among youth in Mozambique.

Lesson Learned: Use Stories

Use stories delivered via SMS to reach young people with SRH content. Findings from the assessment suggest that longer fictional narratives delivered via SMS are a feasible and acceptable way of reaching young people with SRH content. The use of realistic stories to complement informational messages may have contributed to young people’s engagement with the intervention and the positive findings.

Date of Publication: April 20, 2022