ECInfo: Text Messaging Intervention to Increase Correct and Effective Contraceptive Use Among Emergency Contraceptive Users. Kelly L'Engle PHD MPH, Heather Vahdat, MPH.

1. ECINFO: Text Messaging Intervention to Increase
Correct and Effective Contraceptive Use among
Emergency Contraceptive Users
Kelly L’Engle, PhD, MPH
Heather Vahdat, MPH
SHOPS e-conference series
May 5, 2010

2. Overview
• Background
• Formative Research
• Research Design
• Challenges

3. Background
• High mobile phone use in developing
countries
• Reported popularity of texting programs and
promotions BUT:
• Few family planning programs
• Lack of research and evaluation
• Research with EC users in Ghana in 2008 and
2009 found lack of contraceptive knowledge,
everyone had a mobile phone
Photos courtesy: textually.org, thirdi.com

4. Formative Research
• Focus group discussions in Accra, Ghana
• Explored themes related to mobile phone use,
ownership, and texting
• Tested the concept of providing FP information via
mobile phone
• Tested contraceptive message content for
comprehension and trust

5. Formative Research Results: Text Messaging
• Text messaging is very common among mobile
phone users.
• Respondents frequently participated in promotions
that were advertised by text message.
• Respondents suggested promoting ECINFO via
unsolicited text messages to their mobile phones,
since they pay attention to each and every message
they receive.
• Clinics, pharmacies, and mass media also were
frequently mentioned as good points for service
promotion.

6. Formative Research Results: Accra Focus Groups
When asked about how the information provided will be useful:
• “I have two babies and my husband doesn’t like using condoms and I
am not conversant with my menstrual cycle …because I don’t want to
have anymore babies I would [use the service] so that they can refer
me to a particular clinic…so that I can go there immediately and take
control” (female, Ghana)
• “With my girl after she took the emergency contraceptive pills she
asked me a lot of questions about whether or not she may be able to
bear children in future so I think that she may want to know more
[about the service]” (male, Ghana)
• They are making us aware that there are other birth control methods
that are more effective so I’ll text for more [information]” (female,
Ghana)

7. Formative Research Results: Accra Focus Groups
When asked about others potentially seeing the messages on their
phone:
• “When [my partner] asks me that what’s the meaning; like if he sees
other birth control methods are more effective, he will call my attention
to it and I’ll tell him that I’ve read it already” (female, Ghana)
• “My dad sees you; he will tease you and will go like “Eh! W’ahye aseέ
sua mu more yie”, is good, is good, keep on. Meaning eh! You started
learning , is good keep on” (female, Ghana)
When asked about if the service provides new information:
• “[No one] has ever done something like this before; it’s always about
sports, texting bible, love and ringer tones …but when it comes to this
program it will encourage people to [use the system] because they
know that they can get new information about having unprotected
sex…” (female, Ghana)

8. Formative Research Results: Sharing
Participants said they would share the messages with friends,
partners, and family members:
•“You meet in a group, girls talk then l will tell them [about the service],
then l will explain things to them or you even send them the messages
if you saved it” (female, Ghana)

9. ECINFO Research Design: Randomized Trial
Pharmacy promotion of ECINFO
service
Interested pharmacy clients
contact ECINFO
Screener to define eligibility
Non-EC Users EC Users
Ineligibile Electronic Consent Consent not provided
Baseline questions Ineligibile
Randomization
Intervention Control
(n=1450) (n=1450)
Access to EC Plus Access to EC Basic
30-day follow-up 30-day follow-up

10. Study Goals
To investigate whether text messaging is a feasible and effective
means of providing EC users with contraceptive information and
increasing their uptake of highly effective, longer-term methods
To investigate the feasibility of using text messaging on mobile
phones to conduct a randomized research study that relies
exclusively on text for data collection

11. Study Implementation
•Study promotion in pharmacies in Accra, Ghana
•Intervention group will receive messages about proper
EC use as well as persuasive messages promoting the
benefits of OCPs and DMPA; Control group will receive
information about EC use only
•Role model stories will be available to each group
•Analyses based on: (1) text questions and (2) system
use data such as screens accessed, repeat access

12. ECINFO: Role Model Stories
•Role model stories provide basic information about
contraception and the ability to address perceived norms for
contraceptive use
•Utilize a personal tone (i.e., delivered in the first person) to
maximize identification with model, relevance, and salience of
messages
•Incorporate concepts of behavior change to maximize impact
•Intervention group will access role model stories that address
motivators and barriers to use of longer-term methods
•Control group will access EC role model stories that
demonstrates proper use of EC

13. ECINFO: Control Group Content
•Basic EC information
•For example:
Take EC pills up to 5 days after sex. Take first pill
immediately, second pill 12 hours later. Safe for all
women. Not recommended for regular use. Will not
affect existing pregnancy.
•In addition, role model stories demonstrating correct
use of EC

14. ECINFO: Intervention Group Content
Introduction to Role Model Stories
Hi, my name is Beth. Congratulations on using EC and taking control
of your health. Since preventing pregnancy is important to you, I want
to tell you about other contraception that is less expensive and longer
lasting. These methods are great for single and married women. I
know because my friends and I use them. To hear Sandra talk about
daily birth control pills (OCPs), reply J. To learn about OCPs from
Ruth and Isaac, reply R. For my experience with Depo, reply B.
Heighten sense of personal control over health and
pregnancy prevention
Make salient value on pregnancy prevention
Address normative barriers to contraceptive use
Accessible to women and men
Interactive and personal

15. Data Collection Exclusively Via Text
•Contraceptive behavior. For example:
How many times have you used EC in the past 6 months? Reply A for 1
time, B for 2-3 times, C for 4 or more times, D if you have not used EC in
past 6 months. (159 characters)
Contraceptive knowledge and attitudes. For example:
EC only should be used for emergencies and not for ongoing pregnancy
prevention. Reply A if you agree, B if you are not sure, and C if you
disagree. (150 characters)
Changes in bleeding are common and normal with birth control pills and
injectables. Reply A if true, B if false, C if you are not sure. (139
characters)

16. Analysis of Research Process
• Data collection and enrollment via text message
– What % of people who contact ECINFO answer eligibility
question and are eligible?
– What % of people who are eligible answer baseline
questions?
– What % of people who contact ECINFO participate all the way
through follow-up?
• Administering consent via text message
– What % of eligible participants respond to and accept
consent?
• Follow-up response on mobile phones
– What % answer follow-up questions after 30 days?

17. Current Status and Timeline
• Protocol development and ethical review (current)
• Programming and testing of system (April – June 2010)
• Message and usability testing (May-June 2010)
• System refinement and final preparations (June 2010)
• System launch (July 2010)

18. Challenges
1. Platform - literacy, reach, character limits, limits
2. Persuasion - behavior change on mobile phone
3. Programming and Presentation - usability, technical
partner(s)
4. Evaluation—research design, randomization, follow-up,
data collection via text
5. Scale up—sustainability, cost

19. Partners
• The William and Flora Hewlett Foundation
• Text to Change
• Marie Stopes International
• Sliced Bread Design