Background
Methods
Ethics Committee
Results
Literature on determinants of contraceptive use, with a focus on Cambodia
Behaviour change theory
Literature on interventions delivered by mobile phone in other areas
Literature on mHealth in Cambodia
Literature on interventions for contraception including those delivered by mobile phone
Findings from the case note review
Findings from the interviews and FGDs (Table 1)
Related to current abortion |
“If we want to have more children, those who go to school must drop out because we have no enshrined money for their study” (age 30, married, two children) |
“We do not have enough money yet…my husband stays far away from me…he always goes to province” (age 24, married, no children) |
“I discussed with my husband. He said just do what I want to do” (aged 34, married, one child) |
Reported previous experience with contraception use |
“I wasn’t using it regularly so I got sick because of it…it felt hot inside my chest and I felt exhausted… Thus I changed to condom but difficulty is it enables cervicitis” (aged 34, married, one child, talking about previous experience with OC) |
“Because we feel so tired after coming back from the business and we don’t take it regularly or maybe we forget to take it one evening, so we’re lazy” (aged 30, married, two children talking about previous experience with OC) |
“Husband heard from a friend that ‘when we use condom a girl can be burned, it is not good for both husband and wife’. So I followed my husband” (aged 24, married, no children, talking about previous contraception use) |
Reported factors influencing use of post-abortion family planning |
“I am not able to afford any of these methods to prevent pregnancy. If I could afford I would practice the contraceptive method…I think I might wait for my monthly salary” (aged 28, separated, no children, talking about PAFP) |
“Not interested in contraception yet…because my health is not so good” (aged 21, married, talking about plans for PAFP) |
“She told me a lot but I forgot some because there’re a lot of methods” (aged 26, married, no children, talking about PAFP counselling received) |
Reported mobile phone use |
“Even when the company sends messages we can’t read and leave alone the messages sent” (aged 30, married, two children) |
“I don’t really understand the message in the phone” (aged 34, married, one child) |
“My older sister sent a message and I got my husband to read it” (aged 30, married, two children) |
“Husband pays bill but never picks up my phone to answer” (aged 26, married) |
Views on the intervention |
“I think its good because we need contraceptive method to prevent pregnancy, so we need some advice to do this or that” (aged 31, married, no children) |
“Such as service is really good…for women and their health and there can be a lot of side-effects if they have frequent abortions…it means they take care of us” (aged 21, married) |
“We talk on phone, no-one knows our face…If anyone said that they saw us drive here, they would think that we didn’t come here to discuss but to do something, so if we have this programme I think that its very good…it makes clients reduce the time to come directly” (aged 26, married, no children) |
“We are ignorant and cannot read the messages so we leave them we see them, so I suggest talking directly with each other” (aged 30, married, two children) |
Developing a conceptual framework and the final intervention
The MOTIF final intervention comprised a series of automated voice messages to participants’ mobile phones over the three-month period following their abortion, at the time of day of their preference. Clients received the first message within one-week of receiving abortion services and then every two-weeks, with a total of six messages. The main message, recorded in the Khmer language, was as follows: |
‘Hello, this is a voice message from a Marie Stopes counsellor. I hope you are doing fine. Contraceptive methods are an effective and safe way to prevent unplanned pregnancy. I am waiting to provide free and confidential contraceptive support to you. Press 1 if you would like me to call you back to discuss contraception. Press 2 if you are comfortable with using contraception and you do not need me to call you back this time. Press 3 if you would prefer not to receive any messages again’ |
Clients who pressed 1, or who did not respond to the message prompts, received a phone call from a counsellor. The phone calls aimed to support contraceptive use by addressing clients’ capability to use contraception by providing individualised information on a range of contraceptive methods, opportunity to use contraception e.g. informing clients where they could access specific methods near to their residence, and motivation by re-enforcing the benefits of contraception use. If the client requested, the counsellor would also discuss contraception with the husband or partner. Follow-up calls to clients were made during preferred times indicated by the client on her registration form. Clients were also able to call the MOTIF service at any time to request to speak with a counsellor. Clients that chose to receive the OC or injectable could opt to receive additional reminder messages appropriate to their method (e.g. to start a new packet of pills or when to receive a new injection). The sixth and final voice message provided similar information to the first five, but also reminded the client that this would be the last message they will receive. The MOTIF intervention was delivered by trained counsellors at the MSIC head office in Phnom Penh. Voice messages were scheduled and sent using the open-source software programme ‘Verboice’, developed by InSTEDD (instedd.org). MSIC incurred the cost of outgoing communication from the provider to client, and clients incurred any costs calling into the service (the cost of a local call). |
Formative research component | Key findings | Implication for intervention design |
---|---|---|
Insights from contraception literature | • Health concerns identified as major reason for non-use. Other reasons include factors related to access, cost, autonomy | • Intervention needs to address health concerns as well as factors related to access, cost (by nforming clients where they can access contraception near their home) and autonomy |
• Limited evidence for interventions to improve adherence to specific contraceptive methods or uptake of PAFP | • The intervention needs to anticipate some discontinuation and aim to facilitate safe method switching and well as support continuation with existing method | |
• Most discontinuation occurs within the first few months | • Decided to provide intervention for three-months | |
Insights from mHealth intervention and behaviour change literature | •Uni-facteted* adherence interventions have at best modest effects | • Developed a multi-faceted intervention providing information reminders and support to boost motivation to use PAFP |
• A semi-automated mHealth intervention increased adherence to HIV treatment in Kenya | • A similar intervention could be adapted for PAFP in Cambodia | |
Case note review | • 40 % uptake of effective PAFP at the time of seeking abortion services | • An mHealth intervention is an opportunity to maintain contact with clients that don’t return to the clinic for contraception after seeking abortion services |
•Over 50 % clients did not return to the clinic within 12-months | ||
Interviews | • Side-effects with contraception common | • Re-enforced findings from literature that intervention should address health concerns |
• Clients can find it difficult to make decisions about PAFP at time of seeking abortion services | • The mHealth intervention is an opportunity to maintain contact and remind clients about available methods | |
• Women sometimes have to discuss with their husband/partner before using contraception | • Re-enforced findings from literature review that the intervention take into account women’s lack of autonomy, facilitating a discussion with husband/partner if appropriate | |
Focus group discussions | • Preference for voice rather than text-based intervention | • Intervention used voice messages sent to clients phone instead of text-messages |
• Many clients preferred direct phone call to automated message | • Developed a semi-automated intervention as fully counsellor delivered intervention would be costly to scale up | |
• Clients preferred that the messages mentioned the terms ‘Marie Stopes’ and ‘contraception’ | • Voice message mentioned ‘contraception’ and ‘Marie Stopes’, but not the name of the client | |
Consultation with MSIC staff and other organisations | • Text-message interventions likely to have limited success in Cambodia | • Re-enforced findings from clients that intervention should use voice rather than text |
• A fully counsellor delivered intervention would be costly and hence harder to scale-up | • Intervention was semi-automated aiming to identify clients most in need of additional support |