Worldwide the use of mobile phones among young people is dramatically increasing. Even in remote places, young people are using their phones not only as a way of communication but also to look for information. Because of this, IPPF ‘s Member Association in Bolivia has worked with young people to develop a sexual and reproductive health app to complement its routine services. We have also developed and are evaluating a contraceptive intervention delivered through the app to increase use and acceptability of effective contraception among young people. This session will cover the youth-centered design of the app and service delivery aspects of the project, as well as the experience of collaborating with researchers to ensure robust evidence generation. This session will be of interest to those working in inclusive technology projects, researchers, health and public health providers and implementers working in adolescent health and sexual and reproductive health.

1. The development of the ‘Tú decides’ app and an
intervention to increase the acceptability and
use of effective contraceptive use among young
women in Bolivia
Silvia Huaynoca: Program Officer – Technical Advisor, IPPFWHR
Ona McCarthy: Research Fellow LSHTM
Maria Eugenia Torrico and Carolina Aliaga: CIES, Bolivia

2. Collaboration between the International Planned Parenthood Federation
(Western Hemisphere Region), the London School of Hygiene and Tropical
Medicine and the
Centro de Investigacion, Educacion y Servicios

3. IPPF - Innovation Program
 Projects to broaden the contraceptive
method mix to young people
 Research project to know the impact of a
m-health intervention its acceptability
and contraceptive service uptake
 Partnership with LSHTM
Bolivia
Tajikistan
Palestine

4. The project
Phase 1: Formative work that contributed to:
– the development of the ‘Tu Decides’ app and
– an intervention sent by short instant messages through the app
Phase 2: Evaluation of the intervention

5. Research Partnership
 CIES and the research partner developed the intervention
 Integrate evaluation component in the project
 Implement cost- effectiveness analysis of the project

6. IT Partnership
 A local and London- based company worked together to identify the best
mode to deliver the intervention through the mobile phone.
 Reviewed the tech capabilities and young people’s use of mobile phones

7. Bolivia- Reproductive Health
 Progress in family planning has lagged behind
 Unmet need among women aged 15-19: 38%
 Effective contraceptive prevalence in women aged 15-19: 4%
 Adolescent fertility rate: 70 per 1,000 in women aged 15-19
 Around 100 illegal abortions are carried out per day
 84% unmarried sexually active women 15-19 want to avoid pregnancy but only 49%
report using any method
 Main reasons for not using contraceptives: stigma regarding premarital sex, lack of
accurate information regarding the most effective methods

8. Mobile phone-based health interventions
 Many mobile phone-based health interventions globally
 Growing evidence that ‘mHealth’ interventions can be effective in
improving a range of health behaviors
 In sexual and reproductive health, they are advantageous as users can
receive information in private at any time and in any place.
 Capable of reaching many people
 Support can be non-judgemental
 Once developed, often more convenient and cheaper to deliver than face-to-face support

9. Mobile phone-based contraceptive
interventions: evidence from trials
Evidence for improving self-reported contraceptive-related behaviours:
o Daily educational messages can improve pill continuation,
knowledge and injection appointment attendance
o Post abortion voice messages + counselling in Cambodia increased
effective contraception at 4 months and 12 months LARC
*But all trials did not have low-risk of bias and only 1 not in the US

10. Youth- Centered Design
CIES Bolivia worked with their young leaders:
• To gain their feedback on the design and the content of the Tu Decides
app
• To complement its routine services in an innovative way.

11. Tu Decides Development
• We reviewed the content of the application with CIES young leaders
• We incorporated the CIES’ brand in the design of the app
• The local tech partner developed the app based on the preferences of
the young leaders
• We tested the usability of the app with the young leaders

12. App Specifications
• Feature to monitor page views and user demographics (gender, city, age)
• Application available in play store
• Linked to CIES’s server
• Must be light (not use much data)

13. Tú decides

14. Intervention development
Systematic approach for the development of health behaviour change interventions
which involves:
1. Understanding the health problem (unintended pregnancy)
2. Specifying behavioural change
3. Behaviour change methods and their practical applications
4. Producing and refining intervention content
5. Planning for implementation
6. Planning the evaluation

15. Brief results from focus group
discussions and interviews

16. Focus group discussions and interviews:
objective and participants
Objective:
To identify determinants and beliefs that influence effective contraceptive
use in young people aged 18-24 in El Alto
Participants:
• CIES El Alto
• 5 female, 3 male groups
• 2 user interviews, 5 provider interviews
• 69 total participants

17. Mobile Phone Use
• All owned phones, most smart phones (android)
• Majority don’t share phones
• Very enthusiastic about contraceptive information delivered by phone
• Buy data packages (3-7 times a week) enough for FB and WhatsApp
• Main internet use is through mobile phone
• WhatsApp nearly ubiquitous

18. Content and Privacy
• Advantages & disadvantages of methods (strong theme)
• Real stories about other people’s experiences, quotes, curiosities (women)
• Straightforward, brief information about how to use methods
• 1-2 messages a day, (some 2-3)
• No privacy concerns, if can password protect, & prevent pop-ups
• Addresses misconceptions
• Some liked the idea of a call centre so they can talk to a real person
• Directions to services

19. Knowledge
• Good level of awareness of different methods
However, most did not know:
- efficacy of different methods
- advantages & disadvantages
- how much they cost
- how they are used
- where to get them
- how they work
• Very strong expressed need for more information about contraception
• Comprehensive information should start around puberty

20. Attitudes
Some examples:
• Carrying condoms means that you are ‘promiscuous’
• Applies to men and women, but stigma stronger for women
• IUD can rust inside the uterus if it’s not checked
• IUD can implant into a fetus’s head
• It’s a crime for unmarried people to have sex
• IUD causes cancer

21. Barriers
• Services are very busy
• Won’t access services unless there is a problem (pregnancy, STI) b/c
• Assumption is that methods (besides condoms) are expensive
• Providers judge them according to their age
• Worried about what people in general will think

22. Communication
• Not confident talking to providers
• Most parents don’t talk to their children directly
• Some talk to extended family members
• Most are confident talking to close friends
• Most not confident talking to partners unless they know them very well
• Talk about contraception usually happens after beginning a sexual
relationship
• Initiating discussion about contraception too early with a partner might make
them judge you as promiscuous

23. Writing, testing and refining messages
• Messages written based on behavioural theory, behaviour change methods
and what was found from consulting with the target group
• Tested with the target group
• Refined the messages based on the feedback
• Tested again etc.

24. The intervention
• Short mobile phone instant messages sent through Tú decides
• 0-3 messages per day for 120 days
• The messages:
o Provide information about contraception
o Target beliefs identified in the development phase that influence
contraceptive use and
o Support young women in feeling that they can influence their reproductive
health
• Contains 10 behaviour change methods, adapted for delivery by
mobile phone

26. Do messages delivered by mobile phone increase
use and acceptability of effective contraception
among young women in Bolivia?

27. Evaluation
• Randomised controlled trial and interviews
• Aim: to evaluate the effect of the intervention on women’s use and acceptability of effective
contraceptive methods
• Participants: 1310 women aged 16-24 with an unmet need for contraception
• Co-primary outcomes: use & acceptability of effective contraception
• Self-reported data collected by questionnaire at 4 months
• Secondary outcomes: acceptability of individual methods, discontinuation, service uptake,
unintended pregnancy, induced abortion
• Process outcomes: knowledge of effective contraception, perceived norms and personal agency in
using and communicating with partners about contraception, intention to use and intervention
dose received
• Current recruitment = 350 (recruitment closes 31 July 2017)

28. Thank you:
Marcos Mayta
Maria Elena Villarroel
CIES Young volunteers
Cristian Montes
Jose Orosco
Alison McKinley

29. Silvia Huaynoca
Program Officer, Technical Officer IPPF/WHR
shuaynoca@ippfwhr Skype: shuaynoca.ippfwhr
Ona McCarthy
Research Fellow, London School of Hygiene and Tropical Medicine
ona.mccarthy@lshtm.ac.uk
Carolina Aliaga
Research Assistant CIES Bolivia
caliaga@cies.org.bo Skype: caroaliagac