mHealth for Community Health_Birdsong_5.1.12


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  • Hi all. I’m happy to be here today to tell you about CycleTel and share with you research results from this mobile health project in India. My name is Meredith Puleio, and I’m a Program Officer at Georgetown University’s Institute for Reproductive Health at Georgetown University. I currently manage the project from the DC-side of the project and I’m happy to represent the team today, among them – Priya Jha, our Country Representative in India, Rebecka Lundgren, our Director of Research, and Victoria Jennings, our Director.
  • Planning : thinking about activities required to create a desired goalThought process is essentialPartnerships: In this new wave of technology, you can't do it all yourself, alliances are must considering the complexity of ecosystem invloved. Research: To establish / confirm facts
  • As I mentioned before, we are in the process of scaling up SDM is five countries—with the primary goal of ensuring SDM with CycleBeads is consistently available through the national public health system as well as through social marketing outlets. The FAM Project has also afforded us the opportunity to explore other direct-to-consumer approaches for offering SDM that do not rely on the availability of a commodity (in this case, CycleBeads). Unlike many family planning methods, SDM is uniquely suited for direct-to-consumer approaches because it is a knowledge-based method, it does not necessarily require a visit to a provider and it is easy to teach and learn. We were particularly interested in India for direct-to-consumer approaches because our programs have limited geographic reach at the moment and the potential for SDM scale up in immense. To explore alternate ways of offering SDM that do not rely on the availability of a commodityLimited geographical spread of SDM in India, where the potential and need to scale up is immenseMeets the need of all, across economic segmentsCycleTel does not replace CycleBeads, is another way to using SDM
  • I’m pleased to tell you about CycleTel, a live mobile health service in the Delhi region in India that uses text messages (or SMS) to facilitate use of SDM. A woman texts in to join, is screened by sending responses via SMS, and if she is eligible, she is then asked to send in the date of her last menstrual period. Following, she is sent SMS alerts on her fertile days, which you remember are days 8-19 of her menstrual cycle, and she knows that to prevent a pregnancy, she and her partner need to abstain or use a condom on these days. This mobile health service depends on two-way interaction between the user and the service for as long as the woman chooses to continue using CycleTel. To continue use, a woman needs to be motivated to check her phone everyday and send the her period dates each cycle. Slide 6-7: To the 1st knowledge area (how CycleTel works), slides 6-7 describe CycleTel. These are the standard "what is CycleTel and how does it work" slides. 2-3 min
  • The process for developing CycleTel has been a very interesting learning experience for us, especially since the field of mHealth is so new and exciting. We started by designing and implementing a proof-of-concept study, which I’ll go into detail in the next few slides. It was this proof-of-concept study that verified for us that CycleTel on mobile phones was a feasible and acceptable way to offer SDM. Only with that proof did we start software development. After the technology was now built,we tested it with 700 women in a pilot test to ensure that the technology works just as expected. Slide 8: 2nd knowledge area--model for developing a mHealth service. This is the process that we followed that is applicable to others who are developing a mHealth innovation. Emphasis on formative research and ensuring that the concept was viable/appropriate before investing in technology development. This was key, because CycleTel is truly an innovation that was defined by and with the target audience. Two mistakes that other mHealth projects make is that they design the technology without participation from the audience, and that they invest in the technology before they know the idea works. We even figured out a way how to use free open source software to mimic the service with users for 2 cycles of use. This approach was not scalable because it requires an IRH staff member to send/receive messages to all users every day, but it was a short-term testing solution that worked. Then go on to explain (briefly) each of the other phases, popping in the timeline to show that this has been a 2 year process. Technology development and iteration is something that is ongoing, although more and less intensive at different phases -- right now we are in maintenance mode. 3-4 min
  • There were 3 phases to the proof-of-concept research: Phase 1 consisted of focus group discussions with women, men and couples to determine if the CycleTel concept was of interest to the target audience and to better understand phone use patterns. Participants were really interested in the idea, and one male respondent said, “This is an idea that can change your life!:Phase 2 involved cognitive interviews with female interviewees. In this phase, we sent messages to the participants’ mobile device and asked them probing questions to determine if women understood the intent of the messages. This phase was integral in ensuring that the content of the messages were culturally appropriate as well as meaningful – after all, when you only have 160 characters per text to deal with, it’s not so easy to come up with the “right” message for what you are trying to convey. Phase 3 is what we call manual testing. In this phase, we were able to test out how the service would work with actual users before investing in software development. This was made possible by a GSM modem, which can turn your laptop into a mobile phone, and FrontlineSMS, an open-source platform that downloads to your desktop and from which you can send/receive messages. FrontlineSMS helps you keep track of which messages have been sent and received to and from each user. For this phase, we recruited women to use CycleTel for 2 cycles of use, and interviewed them at admission, after the 1st and 2nd cycles of use, and then at exit. We had a staff member in our Delhi office send the appropriate messages to users every day from FrontlineSMS and also serve as a helpline counselor to the users. Through this process, we were able to assess the satisfaction of users, identify issues with content, and get a better understanding of how women interact with the service. I’ve noted here that we completed manual testing in Lucknow, India with 26 women who were age 21-28 who were housewives, and then we repeated the process in Delhi with 88 working women aged 21-30. I’m going to tell you the results of the Manual testing phase in Delhi.
  • Partners are : Innovators, Research Agency, Technology Partner, Helpline support, SMS Gateway Provider, Mobile Operators, Donors & Regulatory AuthoritiesShort conclusion. Say we hope they learned something about each of the proposed knowledge areas. Emphasize that if we identify the right set of partners, we aim to launch CycleTel in 2012.  30 sec or less
  • Partners are : Innovators, Research Agency, Technology Partner, Helpline support, SMS Gateway Provider, Mobile Operators, Donors & Regulatory AuthoritiesShort conclusion. Say we hope they learned something about each of the proposed knowledge areas. Emphasize that if we identify the right set of partners, we aim to launch CycleTel in 2012.  30 sec or less
  • Partnerships become more complex as you go through the development to deployment process. There are technology partners that support the actual functioning of the service (hosting provider, technology partner, sms gateway provider, aggregators), there are quality assurance partners (call center, data management/research organizations), as well as a central partner (such as IRH) that manages the moving parts and maintains ownership over the service. This is the situation for CycleTel in India, and it could very well be different for other mHealth services in other countries.
  • mHealth for Community Health_Birdsong_5.1.12

    1. 1. The Value of Formative Research & Partnerships in mHealth: The Experience of CycleTel™ in India CORE Group May 1, 2012 Susana Mendoza Birdsong Institute for Reproductive Health, Georgetown University
    2. 2. Q:Can we leverage the growing telecomindustry and ubiquity of mobile phonesto expand access to and addressunmet need for family planning inIndia?
    3. 3. A:Our research in India on CycleTelsuggests “yes.” Let me tell you more.
    4. 4. The Standard Days Method® (SDM):A Direct-to-Consumer Approach to Family Planning SDM IS WELL-POSITIONED FOR DIRECT- TO-CONSUMER APPROACHES  Knowledge based  Does not require a visit to a provider (for initiation or re-supply)  Easy to teach & learn VALUE PROPOSITION  As a new FP method, SDM is not yet widely available  Direct-to-consumer approaches expand access to SDM thru avenues outside of health services
    5. 5. CycleTel™Family Planning on the Mobile Phone  What?  A mobile health service that uses text messaging to facilitate use of SDM  Unique: Goes beyond unidirectional provision of health information  How?  Alerts woman of her fertile days via SMS during each menstrual cycle  Requires a woman to send in the start date of her period each cycle  Where?  Tested and built in India
    6. 6. Model: Formative Research to Scale Product Launch Partnership & Scale Development up Business Planning Planned 2012 Planned 2012 Automated Jan-Feb „12 TestingProof-of- Jul „11-Jan „12Concept Sep ‟09 – Jul „11
    7. 7. Structure of CycleTel Proof-of-Concept 3 Phases ObjectivesFocus Group  Understand phone use patterns  Determine potential interest among targetDiscussions audience54 participants  Explore appropriate messaging and preferences for the serviceCognitive Interviews  Verify comprehension of messages18 participants  Adapt and finalize messages (in English & Hinglish)Manual Testing  Enroll women for 2 cycles to assess feasibility,26 women in Lucknow satisfaction and correct method use21-28 years old, housewives  Initially used a low-cost open source software to manually send/receive messages (FrontlineSMS)88 women in New Delhi  Troubleshoot problems and determine how to24-33 years, working women improve service  Determine target audience
    8. 8. Profile of Delhi Phase Participants  Age: 24-33 years; mean age 28.4 yrs  Education: Bachelors degree and above  Employment: 97% employed (either full time or part time)  Children: 97% had children, 52% had 1 child, 48% had 2 children  Current use of FP: 77% were using condoms inconsistently; others were either not using any method or using traditional methods  Mobile phone use: All participants owned a personal mobile phone;15% reported sharing their cell phone with someone regularly
    9. 9. Completion Rates 90 80 88 82 84 80 70# of Participants 60 50 40 30 20 10 10 0 Enrolled 1st Follow-up 2nd Follow-up Female Exit Male Exit
    10. 10. Results: Satisfaction, Ease of Use, Correct Use 100% of users wouldSatisfaction & 92% were very satisfied recommend the service toEase of Use with CycleTel to prevent friends pregnancy Features users liked the most: ease of 98% said it was easy to use, convenience, lack of send/receive SMS side effects 95% participants reported that they received SMS at an appropriate time and that the # of messages sent were the “right amount” 37% of participants 22% reporting havingCorrect Use called the helpline unprotected sex during an during the 1st cycle of unsafe day during the 1st cycle use, 15% called during of use; this decreased to 13% during the 2nd cycle of use the 2nd cycle of use
    11. 11. Results: Male Involvement & Willingness to Pay 23% expressed interested in Male 76% said it was easy to having their husbandInvolvement tell their husband that it receive unsafe day alerts was an unsafe day. too About 70% of women reported showing their husbands messages from CycleTel 83% of users said that they would be willing toWillingness to Pay pay on average Rs. 33 per month for the CycleTel service, ranging from Rs. 15-400 (US $1 = Rs. 45)
    12. 12. Using Research Results to Design the Innovation Confirmed timing and frequency of messages Identified messages that could be improved based on user-feedback Confirmed need for a call center Identified issues with the service‟s functionality (e.g., some women had issues with the screening questions and we are exploring other options to improve the experience) Determined that men do not necessarily want to receive the messages, but some would like to have the option Determined attributes of the service (e.g., ease of use, no side effects, confidential) that could be used in marketing campaigns
    13. 13. Key Takeaways: Value of Formative Research Proof-of-concept results and user-feedback were critical to design and develop a service that met the needs of the target population. There are low-cost open source platforms available (e.g., FrontlineSMS) that can help an organization test a concept. Only with proof-of-concept results did IRH move forward with investing in technology development.
    14. 14. A Note on PartnershipsFORMATIVE RESEARCH Lead org. – IRH Research Agency FrontlineSMS PILOT TESTING Donor - USAID  Lead organization – IRH  Technology partner – ThoughtWorks  SMS Gateway Provider – Unicel  Hosting Provider PUBLIC LAUNCH & SUSTAINABILITY  Call Center – ISHP  Research Agency  Lead organization – IRH?  Donor - USAID  Technology partner  Aggregators/Mobile operators  SMS Gateway Provider  Hosting Provider  Call Center  Data Management Organization  Marketing Agency  Regulatory Authorities  Donor(s)
    15. 15. CycleTel ™ Family planning via SMSFor more information, contact Meredith Puleio at or visit