Efficacy of a Digital Health Tool on Contraceptive Ideation and Use in Nigeria: Results of a Cluster-Randomized Control Trial

"An IVR-based approach using drama is a viable option for promoting positive ideation related to family planning and increasing contraceptive use."

Communication is a core skill running throughout the decision-making process about contraception, but female clients are often passive participants in family planning counseling. The Health Communication Capacity Collaborative (HC3) family planning team leveraged the power of basic mobile technology to develop a digital health tool, Smart Client (or Beta Life in Nigeria), to encourage them to talk with their provider and partner about contraceptive methods. This cluster-randomised control trial (RCT) assesses the effects of exposure to the digital tool on contraceptive ideation and use among women of reproductive age in Kaduna City, Nigeria.

Using an entertainment-education approach, Smart Client adapts a drama format to basic mobile phones via interactive voice response (IVR) in an effort to increase the number of family planning clients who are informed, empowered, and confident; more information about the tool is available at Related Summaries, below, and here. In brief, the intervention is based upon Social Learning Theory, which posits that people learn from each other through observation, imitation, and modeling. Smart Client therefore incorporates fictional role models, who demonstrate the desired behaviours and behaviour change process, as well as personal stories and examples of smart client dialogues. This approach allows the intended audience to observe an action, understand its consequences, and become motivated to repeat and adopt it. The purpose is to prepare clients to be active and engaged communicators during their interactions with the family planning service provider.

The study took place in North and South Kaduna local government areas (LGAs) of Kaduna State, Nigeria, from March 7 2017 to June 5 2017. Twelve wards in the city were randomly assigned to intervention (6 wards) and control (6 wards) arms of the study. A total of 565 women aged 18-35 years completed a baseline survey. The women in the intervention group were registered to receive 1 welcome call, 13 programme calls, and 3 quiz calls on their mobile phones. Each regular programme call included 5 segments: a brief welcome; a short drama that follows a couple, Laila and Musa, and some of their friends as they face challenges and make decisions about contraceptive use; a "friend-to-friend chat" in which the hosts reinforce the key messages included in the drama segment and ask the user a quiz question; an optional personal story segment; and an optional sample dialogue between a friendly provider and a client, modeling what to expect during a family planning clinic visit and how to discuss needs, preferences, and concerns. Women in the control arm received no intervention.

The results of both per-protocol and intent-to-treat analyses show that the intervention was efficacious in improving relevant ideational and behavioural outcomes. For example:

• Thoughts about desired family size - At the post-study, essentially no change had occurred in the control group. However, proportionally more women in the intervention group reported having ever given thought to the desired family size. The per-protocol Differences-in-Differences (DID) estimate shows that the intervention led to a significant 43.2 percentage point increase in this indicator.
• Confidence in one's ability to discuss concerns about contraceptive methods with a provider - According to the results of the per-protocol analysis, between pre-study and post-study, the proportion of participants confident in their ability to discuss concerns about contraceptive methods with a provider increased significantly in the intervention group (from 35.5% to 73.6%), whereas it declined dramatically in the control group (from 59.5% to 36.1%). Results of the per-protocol DID estimation reveal a 61.5 percentage point increase in this indicator attributable to the intervention.
• Discussion of desired family size with one's spouse - At post-study, the indicator remained practically unchanged in the control group (66.7%) but increased in the intervention group (from 74.6% to 98.5%). The per-protocol DID estimate is 41.2 percentage points.
• Discussion of contraceptive methods with one's spouse - The per-protocol analysis revealed that discussion of contraceptive methods with their spouse became more prevalent between pre-study and post-study in both the control (from 43.0% to 49.7%) and intervention (46.4% to 75.8%) groups. The DID estimate was marginally significant at 22.7 percentage points.
• Rejection of the misconception that contraceptive methods can harm the womb - Results of the per-protocol analysis showed increased rejection of this misconception in the intervention group between pre-study (50.6%) and post-study (78.8%). In contrast, in the control group, proportionally fewer women (43.9%) at post-study rejected the misconception than at pre-study (64.1%). The per-protocol DID estimate stood at 48.4 percentage points.
• Current use of modern contraceptive methods - Whereas the use of modern contraceptive methods increased in the intervention groups (from 28.8% at pre-study to 63.6% at post-study), it remained at the same level in the control group (32.7%) at both time points. The estimated DID was 34.8 percentage points using the per-protocol approach and 14.8 percentage points using the intention-to-treat analysis.

One major challenge encountered during the study was the high attrition rate; the researchers stress that "the potential for noninitiation and high drop-out rate is a problem that should be accounted for when using mobile phone technology in the context of health behavior change interventions." They examine some of the reasons behind this and make some suggestions for future efforts. For example, it might be helpful to inform participants at the time of recruitment of what the opening segment of the calls will sound like to avoid the calls being mistaken for telemarketing calls. In addition, intensive testing prior to scale-up could prevent potential attrition due to technical issues.

In addition to addressing issues related to recruitment and initiation, future adaptations of the tool could consider shortening the content, eliminating segments, or splitting the segments into separate calls, so the calls are not so long, and potentially include husbands so they are able to listen to the content and discuss it with their wives.