6 in 10 people around the world now have a cell phone subscription. Two-thirds of the world’s 4.1 billion cell phone users live in developing countries! SMS represents a way to transmit timely, personalized health messages directly to a person’s cell phone. India topped 350 million cell phone users in 2008! Both urban and rural use is driving growth. (more information below) Jan 26, 2009 (Arab News - McClatchy-Tribune Information Services via COMTEX) -- VOD | Quote | Chart | News | PowerRating -- India has emerged as the fastest growing telecom market in the world, attracting not just global service providers like Britian-based Vodafone but also big handset manufacturers like Finland's Nokia that not too long ago was reluctant to make an entry because of low volumes. For a country that stood at the bottom of the pyramid in terms of telecom penetration a decade ago, 2008 was a watershed when India's subscriber base topped 350 million users to make its network the second largest in the world after China , displacing the US. Going by the recent data compiled by industry watchdog Telecom Regulatory Authority of India (TRAI), the growth is being powered with equal fervor by rural areas, once regarded as low-end, low-volume markets with modest purchasing power. http://abcnews.go.com/Technology/wireStory?id=6986939 http://www.tradingmarkets.com/.site/news/Stock%20News/2141955/
Other projects utilize SMS technology to provide health-related information directly to users (e.g., One World’s Mobile4Good in Kenya, SIMpill ® Medication Adherence System in South Africa and Bostwana). No current application guides family planning method-use. The Standard Days Method is uniquely appropriate for this intervention. The woman will only have to provide the date her menstrual period starts (each cycle), after which she can be advised of her fertility status on a daily basis via text messaging. Additional messages support correct use of the Standard Days Method, monitor her cycle lengths to identify whether they are in the 26-32 day range, and offer information on other family planning options and reproductive health issues, with an emphasis on the importance of healthy timing and spacing of pregnancies. As the project develops, women and men will be able to access, via SMS, answers to their questions about the Standard Days Method and other frequently-asked questions about reproductive health issues.
CycleTel is an mHealth solution that will pioneer supplying a modern family planning method directly to a user’s mobile phone. No other application exists that offers a modern family planning method directly to a user’s handset.
The Standard Days Method identifies days 8 – 19 of the menstrual cycle as the fertile days, when there is a significant probability of pregnancy. On all the other days of the cycle, pregnancy is most unlikely. The method works best for women who have cycles between 26 and 32 days long. Therefore, to use the Standard Days Method to prevent pregnancy, couples avoid unprotected sex from day 8 through day 19 of each cycle. On all the other cycle days, they can have unprotected sex. To plan pregnancy, the Standard Days Method can help a couple identify the days to have sex. While this is not sufficient for all couples, it can be an important first step. The Standard Days Method is used with CycleBeads TM , a color-coded string of beads to help a woman Track her cycle days Know when she is fertile Monitor her cycle length Many people also find that CycleBeads are an important factor in gaining the man’s support to use the method. It is very visual – he can literally see when the woman is on a fertile day.
Key questions to have answered before investing large technology development costs: Does the need and demand exist for the mHealth service? Is it a local solution for a local problem?
Uttar Pradesh is the yellow state
“ Had a need for family planning” means they wanted to avoid a pregnancy but were using either no method, a traditional method, or condoms inconsistently
For testing in another country, can mention Philippines and Rwanda, but try to be vague! We don’t want to mention countries where we don’t have current government support to do the testing. Software development: IRH is partnering with Voxiva, Inc. as the technology provider for CycleTel. Since 2001, Voxiva has delivered mobile information solutions for real-time data collection, analysis, patient interaction and support via their unique, award-winning technology platform. Voxiva, Inc. (www.voxiva.com) is a privately held, socially responsible technology company, with headquarters in the District of Columbia and offices in Lima, Peru, and Delhi, India. Voxiva’s mission is to provide practical, innovative and scalable ICT solutions to improve the health, safety and well-being of people in the developing world. Voxiva is a leading worldwide provider of mobile-centric information and communication technology (ICT) solutions for public and private sector development agencies. Voxiva solutions let governments and other partners collect and analyze real-time data from the field, and communicate and interact with their staff and patients more effectively. Voxiva solutions leverage the world's four billion mobile phones as well as fixed-line phones, PCs, smart phones, the web, and other technologies for a much broader reach than Internet-only solutions. The application has the potential to operate at scale, across multiple countries and in different languages. The application can handle a high volume of users and messages (initially 500 users, with the potential of reaching millions based on demand). Voxiva’s system is able to send as many as 200 SMS messages per second and has proven ability to support expanding messaging and data needs as projects scale. Data collection occurs in real time and is stored in one central database, accessible to researchers and project managers at any time from any PC connected to the internet. IRH and Voxiva are in discussion with community groups and messaging services, SMS aggregators, and cell phone service providers. Negotiate competitive pricing on in- and out-bound messages with local aggregators and telcos.
Refer to next slide for scale up considerations
IRH has significant experience with multi-country scale-up of the Standard Days Method (using CycleBeads) in public and private non-profit health and community development systems, utilizing the World Health Organization’s ExpandNet model. This experience translates to scale up of CycleTel and there are various aspects that need to be considered. Moving forward, the focus on collaborative implementation, engagement of local partners, monitoring and evaluation, and information sharing will be integral to scale-up. To ensure acceptance of the application and its sustainability within the target markets, IRH and Voxiva will engage other partners (cell phone companies, aggregators, social marketing companies) and user communities whose members may be interested in the CycleTel service. When the system becomes available, the CycleTel number will be integrated into existing materials (billboards, brochures, etc.) that are already distributed throughout the target countries. Share information on project status with local stakeholders and international audiences to enhance potential for sustainability and scale-up.
Family planning via mobile phones: Proof-of-concept testing in India (CycleTel)
Family planning via mobile phones: Proof-of-concept testing in India K. Lavoie, V. Jennings, M. Puleio, P. Jha, R. Lundgren Institute for Reproductive Health, Georgetown University
Mobile phone landscape <ul><li>Fastest growing technology in developing world and recognized as a powerful tool for international development </li></ul><ul><li>3 billion (out of 4.1 billion) use SMS </li></ul><ul><li>Majority of subscribers men and women ages 15-49 </li></ul><ul><li>India has fastest growing telecom market in the world </li></ul><ul><li>Rural and urban areas driving growth </li></ul>
Mobiles for health (mHealth) <ul><li>Data collection </li></ul><ul><ul><li>MIS, patient records, monitoring, program coordination </li></ul></ul><ul><li>Health education </li></ul><ul><ul><li>providing health information to population (promotion, prevention, medication adherence, VCT services, etc.) </li></ul></ul><ul><ul><li>mLearning (i.e. training of CHWs) </li></ul></ul><ul><li>Telemedicine </li></ul><ul><ul><li>administering healthcare to patients from a distance </li></ul></ul>
<ul><li>mHealth solution for the Standard Days Method® (SDM) </li></ul><ul><li>Woman sends the date of her menses </li></ul><ul><li>User receives text messages with fertility status </li></ul><ul><li>Additional messages support correct use, info on other RH issues </li></ul>CycleTel : The Concept Safe day!
Standard Days Method ® (SDM) <ul><li>What is SDM? </li></ul><ul><li>Identifies days 8 to19 of the cycle as fertile </li></ul><ul><li>Appropriate for women with menstrual cycles 26-32 days long </li></ul><ul><li>Couples use condoms or avoid sex on fertile days to prevent pregnancy </li></ul><ul><li>Facts: </li></ul><ul><li>Modern natural family planning method </li></ul><ul><li>95% effective with correct use </li></ul><ul><li>Included in international FP guidelines (WHO) </li></ul><ul><li>Offered over 30 countries worldwide </li></ul>
<ul><li>Confirm interest in the concept among target population </li></ul><ul><li>Ensure that the technology and content are appropriate for the environment and the intended users </li></ul><ul><li>Enable users to have input into the service and guide development of product </li></ul>Value of proof-of-concept testing
<ul><li>Urban population of 2.7 millions </li></ul><ul><li>14% of women use traditional methods </li></ul><ul><li>16% of women have unmet need for family planning </li></ul><ul><li>Previous research by IRH suggests that SDM is a feasible and desirable FP option </li></ul>Target population: Lucknow, Uttar Pradesh
Research Methods 3 Phases Objectives Focus Group Discussions <ul><li>Understand phone use patterns </li></ul><ul><li>Determine potential interest among target audience </li></ul><ul><li>Explore appropriate messaging and preferences for the service </li></ul>Cognitive Interviews <ul><li>Verify comprehension of messages </li></ul><ul><li>Adapt and finalize messages </li></ul>Manual testing with ~30 couples <ul><li>Enroll women for 2 cycles to assess feasibility, satisfaction and correct method use (using FrontlineSMS software) </li></ul><ul><li>Troubleshoot problems and determine how to improve service </li></ul>
<ul><li>54 participants interviewed: </li></ul><ul><ul><li>4 groups of women (n=32) </li></ul></ul><ul><ul><li>2 groups of men (n=16) </li></ul></ul><ul><ul><li>1 group of couples (n=6) </li></ul></ul>Phase 1: Focus group discussions <ul><li>All focus group participants: </li></ul><ul><li>Married, age 18-28 </li></ul><ul><li>Owned a mobile </li></ul><ul><li>Had need for family planning </li></ul>
<ul><li>Strong interest among men and women in natural methods, but lack correct knowledge of fertile days </li></ul><ul><li>Both women and men are interested in the service </li></ul><ul><li>Service fits within mobile phone use patterns of target population </li></ul>Finding 1: Need and demand exists. <ul><li>Preference for “safe/unsafe day” rather than “you can/cannot get pregnant today” to protect privacy </li></ul><ul><li>Preference for messages only on unsafe days </li></ul><ul><li>Prefer minimum information about length of fertile window (only when it begins/ends) </li></ul>“ This is an idea that can change your life.” -Male participant Finding2: Messages should be precise, non-technical. Phrase “fertile day” perceived as degrading to women.
<ul><li>Messages should be Hindi words spelled with Roman alphabet </li></ul><ul><li>Prefer text rather than voice messages </li></ul>Finding 3: SMS - in Hinglish – are best. <ul><li>Half of the male respondents through both partners should receive messages. </li></ul><ul><li>Women: Rs 20-25 </li></ul><ul><li>Males: Rs 15 </li></ul><ul><li>Couples: Rs 30-35 </li></ul>“ Aaj asurakshat din hai.” Finding 4: Males may sign up for the service. Finding 5: People are willing to pay for a monthly service.
Lessons for mHealth <ul><li>Confidentiality is an issue – even when cell phones are individually owned. </li></ul><ul><li>Assess feasibility of sending messages in languages based on non-Roman alphabet. </li></ul><ul><li>Reduce frequency of messages and keep wording precise. </li></ul><ul><li>Ensure that the mHealth solution addresses a definite local need. </li></ul>
Next steps for CycleTel <ul><li>1. Complete proof-of-concept testing </li></ul><ul><li>Cognitive interviews </li></ul><ul><li>Manual testing with couples using open source software, FrontlineSMS o/ </li></ul><ul><li>2. Software development </li></ul><ul><li>Technology partner: Voxiva, Inc. </li></ul><ul><li>Considerations: flexible platform, real time data collection, interoperable, handles large # of long-term users, able to send high volume of messages </li></ul>
<ul><li>with ~500 users </li></ul><ul><li>adapt technology accordingly </li></ul>3. Pilot test software in India Next steps continued… 4. Expansion in India and adaptation/launching of innovation in other countries
Considerations for expansion <ul><li>Engage stakeholders in the implementation process and keep them informed </li></ul><ul><li>Build multi-disciplinary partnerships with businesses, government, NGOs & mobile service providers to leverage resources and ensure sustainability </li></ul><ul><li>Market service to raise awareness among potential users </li></ul><ul><li>Monitor & evaluate: </li></ul><ul><ul><li>Collect data about usability & continuation </li></ul></ul><ul><ul><li>Evaluate process and impact </li></ul></ul><ul><ul><li>Make mid-course corrections </li></ul></ul><ul><li>Share information about the project with others engaged in the use of mHealth, incorporate feedback (i.e. mHealth Working Group) </li></ul>
Conclusions <ul><li>Preliminary research suggests that there is a demand for this service </li></ul><ul><li>CycleTel could help expand access to family planning and reduce unmet need </li></ul><ul><li>Proof-of-concept testing, pilot-testing, and skillful management of implementation process are important </li></ul><ul><li>Future considerations include using CycleTel platform to transmit other health messages (HIV prevention, etc) to core application </li></ul>