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SmartClientandSmartCouple:DigitalHealthToolstoEmpower

WomenandCouplesforFamilyPlanning

PART1:BACKGROUNDANDDESCRIPTION

September2017

SmartClientandSmartCouple–Part1:BackgroundandDescription page2

Contact:

HealthCommunicationCapacityCollaborativeJohnsHopkinsCenterforCommunicationPrograms111MarketPlace,Suite310Baltimore,MD21202USATelephone:+1-410-659-6300Fax:+1-410-659-6266www.healthcommcapacity.org

Coverphoto:WomanlisteningtoSmartCoupletoolonmobilephone.©2017,CaitlinLoehr,allrightsreserved.

ThisreportwasmadepossiblebythesupportoftheAmericanPeoplethroughtheUnitedStatesAgencyforInternationalDevelopment(USAID).HC3issupportedbyUSAID’sOfficeofPopulationandReproductiveHealth,BureauforGlobalHealth,underCooperativeAgreement#AID-OAA-A-12-00058.

©2017,JohnsHopkinsUniversity.Allrightsreserved.


TABLEOFCONTENTS

ACKNOWLDGMENTS....................................................................................................................................4

ACRONYMS...................................................................................................................................................4

INTRODUCTION............................................................................................................................................5

BACKGROUND..............................................................................................................................................5

PURPOSE......................................................................................................................................................7

INTENDEDAUDIENCES.................................................................................................................................7

BEHAVIORALOBJECTIVES.............................................................................................................................8

SMARTCLIENT/COUPLEAPPROACH..........................................................................................................10

KEYELEMENTSOFTHETOOLS...................................................................................................................11

TESTINGTHETOOLS...................................................................................................................................14

REFERENCES...............................................................................................................................................15


ACKNOWLDGMENTS

TheHealthCommunicationCapacityCollaborative(HC3)–fundedbytheUnitedStatesAgencyforInternationalDevelopment(USAID)andbasedattheJohnsHopkinsCenterforCommunicationPrograms(CCP)–wouldliketoacknowledgethefollowingindividualsfortheircontributionstothisproject:

• CaitlinLoehr,AllisonMobley,JoannaSkinnerandArzumCiloglufromHC3;• Dr.StellaBabalolaandOlamideOyenubifromtheCCPresearchdepartment;• AkinsewaAkiodefromtheNigerianUrbanReproductiveHealthInitiative;• ReginaTraore-SerieandBenjaminSorofromCCPCoted’Ivoire;• DesmondNwekeandMarketAuditsandResearchServices(MARS),NIgeria;• ClémentKouadioKouame,researcherinCoted'Ivoire;• AfricanRadioDramaAssociation(ARDA),Nigeria;• SpotLine,Coted'Ivoire;and• HopeHempstone,RachelMarcus,JoanKraftandAfeefaAbdur-RahmanfromUSAID.

ACRONYMS

FGD FocusGroupDiscussion

FP FamilyPlanning

HC3 HealthCommunicationCapacityCollaborative

IVR InteractiveVoiceResponse

SBCC SocialandBehaviorChangeCommunication

SDA SmallDo-ableAction

SMS ShortMessagingSystem

USAID UnitedStatesAgencyforInternationalDevelopment


INTRODUCTION

ThisdocumentprovidesanoverviewoftheSmartClientandSmartCoupledigitalhealthtoolsdevelopedbytheFamilyPlanningteamoftheHealthCommunicationCapacityCollaborative(HC3)project.Thetoolsprovideuserswithentertainingcontenttohelpthembecomeinformed,empoweredandconfidentusersoffamilyplanningservicesandmethods,orsupportivepartnersoffamilyplanningusers.

Thecontentisdelivereddirectlytothetoolusers’mobilephoneswithinteractivevoiceresponse(IVR)technology.BothSmartClientandSmartCouplearemadeupof17voicecalls,eachofwhichincludesdifferentsegmentssuchasadrama,chatsbythemaleandfemalehosts,apersonalstoryandsampledialogue.Inaddition,aftereachcallusersreceiveashortmessageservice(SMS)messageeitherwithareminderaboutthekeymessagefromthepreviouscalloraprompttodiscusscontentfromthepreviouscallwiththeirpartner.

Thetwotoolssharemuchofthesamecontent,butthereisaslightdifferenceintheintendedaudienceandadditionalcontentintheSmartCoupletool.WhereastheSmartClienttoolisdesignedforfemaleusers,theSmartCoupletoolisintendedforcouples.Assuch,theSmartCoupletoolfeaturesadditionalcontentdirectedtowardmenandmessagesencouragingcouplecommunicationandequitableparticipationbybothmaleandfemalepartnersthroughouttheprocessofdecidingaboutandadoptingfamilyplanningmethods.

ThisisPartOneofafour-partdocument.PartOneprovidesthebackgroundforthetools,visionandobjectives,detailsabouttheaudienceandbehavioralobjectives,andinformationaboutkeyaspectsaboutthetools.PartTwoistheSmartClientcharacters,scriptsandSMSreminders.PartThreeistheSmartCouplecharacters,scriptsandSMSchallenges,andPartFourprovidesguidelinesforadaptation.

BACKGROUND

Womenandmeninterestedinplanningtheirfamiliesoftengothroughaprocessofdeliberationanddecision-makingastheychoosewhethertoadoptfamilyplanning,whatmethodtouse,wheretoobtainitandwhethertocontinueusingit.Duringthisprocess,awomanormanmayconsiderherorhisownfertilitydesires,seekoutinformationonfamilyplanning,talkwithherorhispartner,anddiscussexperienceswithfamilyandfriends.Atsomepointinthisprocess,aclientislikelytovisitwithaprovider1–whichisonebrief,butimportant,pointintimeinthisdecisionprocess.

Communicationisacoreskillrunningthroughoutthisprocess–communicatingwithone’spartner,communicatingwithfamilyandfriends,andcommunicatingwithahealthcareprovider.Inaddition,communicationbetweenpartnersandjointdecision-makinghasbeenlinkedtoanincreasedlikelihoodthatfamilyplanningmethodswillbeusedeffectivelyandoverthelongterm(Feyisetan,2000;Hartmann,2012;Lasee&Becker,1997;Lozare,1976;Oni&McCarthy,1991;Salway,1994;Sharan&Valente,2002).However,womenandmenareoftennotequippedwiththeskillstheyneedto

1 Theterm“provider”isusedinthistooltorefertoanypersonthataclientmayobtainfamilyplanningfrom.Thismayincludedoctors,nurses,midwives,communityhealthworkersandpharmacistsinthepublicorprivatesector.However,acentralmessagefortheaudienceisthata“smartclient”shouldgotoaproviderformorecompleteinformationandFPoptions.


communicateeffectivelyaboutpersonalandsensitivesubjects–suchassex,fertilitydesiresandusingfamilyplanningmethods–thatmaygoagainstculturaltaboos.Furthermore,wherefamilyplanningisfrequentlyregardedasawoman’sissue,menmaynotwanttobeinvolvedormaythinktheyshouldnotbeinvolvedthroughouttheprocessofadoptingorcontinuingtousefamilyplanning,includinginitiatingdiscussionwiththeirpartner,seekinginformation,attendingcounseling,choosingamethodandsupportingtheirpartnerinusingtheirchosenmethod.

Manydemandgenerationprogramsaddressthecommunicationneedsoffemaleclientspriortovisitingaprovider,andencouragethemtoseekoutfamilyplanningcounseling.Butthoseprogramsusuallyfallshortinpreparingtheclienttobeactiveandengagedcommunicatorsduringthecounselingitself,nordotheprogramsencouragementobeactiveandengaged.Furthermore,inmanycountriesandsettings,effortshavebeenmadetoimproveproviders’communicationskillsandprovideclient-centeredcounseling(seeBox1),whichhasledtosomeimprovementinclientengagement,buttheclientisdependentontheprovidertoleadthisprocess.Thisistroublesomegiventhatsocialandgendernormsoftendonotsupportengagedandempoweredclients,especiallyfemaleclients.Asaresult,femaleclientsareoftenpassiveparticipantsinfamilyplanningcounseling,resultingindiscussionanddecision-makingledbytheprovider.Inothercases,suchascultureswheregenderandsocialnormsarounddecision-makinglimitwomen’smobilityoutsideofthehomeandcontrolofmoney,menmayultimatelymakethedecisionabouttheuseoffamilyplanningmethodsorwomenmaydefertomentomakeadecision.

TheHC3project,ledbytheJohnsHopkinsCenterforCommunicationPrograms(CCP),isinterestedinincreasingthenumberoffamilyplanningclientswhoareinformed,empoweredandconfident–inotherwords“smartclients”–withoutrelyingexclusivelyonproviderstodirectandleaddiscussionanddecision-making.Weenvisionthat“smartclients”willbepartofa“smartcouple”wherebothpartnersareinformed,supportiveandequallyinvolvedinmakingdecisionsandtakingactionsrelatedtotheuseoffamilyplanningservicesandmethods.

Giventheglobalproliferationofmobiletechnologiesandthesuccessoftheiruseincreasingwomen’sknowledgeabouttheirhealth(i.e.,MobileAllianceforMaternalAction(MAMA)inBangladeshandSouthAfrica,MOTECHinGhanaandMobileforReproductiveHealth(M4RH)KenyaandTanzania)HC3isusingthistechnologytodevelopadigitalhealthtooltopreparesmartclientsandencouragethemtotalkwiththeirprovideraboutcontraceptivemethods.ThisdocumentoutlinestheHC3SmartClientdigitalhealthtoolapproach,objectives,intendedaudiencesandcontent.

Client-centeredfamilyplanningmeansthat:

• Clients’needsdrivetheprovisionoffamilyplanningservices;

• Providerstailorcounselingtoanindividualclient’sneeds;

• Clientsareawareoftheirrightsandhavetheknowledgetheyneedaboutmethods;

• Clientsactivelyparticipateinthecounseling;and

• Clientsmakethefinaldecisionofwhethertousefamilyplanning,andwhichmethodtouse.


PURPOSE

ThepurposeoftheSmartClientandSmartCoupledigitalhealthtoolsistoinform,empowerandpromotesmartclientsandsmartcouplesbyreachingthemdirectly,usingmobiletechnology.Thesetoolsareintendedtobeadoptedasan“add-on”componenttoexistingfamilyplanningprogramsinresourceconstrainedsettings.Theycanbeusedinbothdemandgenerationandservicedeliveryprogramsthatwouldliketoincorporateaclient-focusedinterventioninimprovingclient-providercommunication.Assuch,thedigitalhealthtoolwouldbeespeciallyappropriateforusealongsideprovider-focusedinterventionsaimedatimprovingprovidercommunicationandcounselingskills.

INTENDEDAUDIENCES

Theintendedaudiencesforthedigitalhealthtoolsarewomenandmenofreproductiveage.

TheprimaryaudienceforSmartClientiswomen,18to45yearsold,whoaremarriedorunmarriedandliveinurbanandotherareaswhereaccesstomobilephonesisgreater.Theyarelow-mediumeducationandincomelevelandmaybecurrent,pastorneverusersoffamilyplanning.Malepartnersarethekeyinfluencingaudience.TheprimaryaudienceoftheSmartCoupletooliscoupleswiththosesamecharacteristics.

TheSmartClient/Couplemobilephonetoolsaredesignedtobebroadlyapplicableandrelevanttowomenandmenofreproductiveagewithawiderangeofdemographiccharacteristics,allofwhommaybenefitfromstrengtheningtheirsmartclientskills.Becausethetoolisdesignedtobeusedandpromotedbyabroaderfamilyplanningprogram,allintendedusersareexpectedtohaveheardoffamilyplanningandbeenexposedtoafamilyplanningpromotionprograminsomeway.Thestoryandmessagecanhoweverbetailoredtobelocallyspecificasneeded.


BEHAVIORALOBJECTIVES

Theobjectivesaregroupedaccordingtothestageofthecounselingvisit.

Objectives

BeforeCounseling

Increasetheproportionofwomen/men/coupleswhohaveconsideredtheirneedsanddesiresbeforevisitingafamilyplanningproviderIncreasetheproportionofmenwhosupporttheirpartnersinseekingfamilyplanningcounselingwhenneededIncreasetheproportionofwomen/men/coupleswhohavediscussedfertilitydesiresandfamilyplanningwiththeirpartner

DuringCounseling

Increasetheproportionofwomen/menwhoactivelyparticipateinfamilyplanningcounselingIncreasetheproportionofwomenusingfamilyplanningwhofeelconfidenttodiscussproblemsandconcernswithaprovider

AfterCounseling

Increasetheproportionofmenwhosupporttheirpartners’useoffamilyplanningIncreasetheproportionofwomenwhoexperiencedifficultieswithafamilyplanningmethodandreturntoaproviderforadditionalcounselingIncreasetheproportionofwomen/menusingfamilyplanningwhoadvocatetheuseoffamilyplanningtotheirfriendsandfamily

Profilespresentedhereillustrateboth“before”and“after”archetypesoftheintendedaudiences(seeTable1:IntendedAudiences).ThebeforearchetyperepresentstheaudiencebeingtargetedwiththeSmartClienttool,showingtypicalbeliefsandattitudesaswellasbarrierstoovercome.Asanintendedaudience,thereisanassumptionthatsheorheisnotalreadyperformingthedesiredbehaviors.TheafterarchetypeassumesthattheSmartClientinitiativehasbeensuccessful,andthispersonisnowperformingthedesiredbehaviorsandmeetingtheinitiative’sbehaviorchangeobjectives.


Table1:IntendedAudiencesandArchetypes(beforeandafter)

BeforeArchetype AfterArchetype

Femalefamilyplanningintenders(neworre-initiatingusers)

Shehasheardaboutfamilyplanningandmaybeconsideringvisitingaprovider.Shemighthavehadapreviousexperiencewithfamilyplanningthatwasnegative.Shehassomeconcernsandquestionsaboutfamilyplanningmethods,suchaseffectiveness,safetyandsideeffectsbuthasnotyettalkedwithahealthprovideraboutfamilyplanning.Ifsheisinarelationship,shemaynothavediscussedherfertilitydesireswithherpartnerortalkedaboutfamilyplanningbecauseitisdifficulttostarttheconversation,shedoesn’twanttoappearuncommittedtotherelationshipandmayhavemisconceptionsaboutherpartner’sattitudesandbeliefsonthissubject.Sheisquietwithauthorityfigures,sincethatiswhatisoftenexpectedofwomen.Assuch,sheisusedtolettingdoctors,midwivesandnursesmakeallthedecisionsasshethinkstheyknowbest.

Shefeelsconfidenttovisitaproviderandactivelyparticipateincounseling.Shehasthoughtaboutherfertilitydesires,questionsandconcernsaboutfamilyplanningmethodsbeforeseeingaprovider.Shehasalsotalkedwithherpartner,ifshehasone,aboutwhattheywantfortheirfutureandhowbirthspacingorlimitingandusingfamilyplanningcanhelpthemmeettheirgoals.Whenvisitingaprovider,shesharesherneeds,desiresandotherinformation–bothspontaneouslyandinresponsetotheprovider’squestions.Shealsoasksquestionsoftheproviderandseeksclarificationsasnecessary.Shebelievesthatthedecisionofwhetherornottousefamilyplanningandwhatmethodtouseisultimatelyherstomake(aloneorwithherpartner),withsupportandguidancefromaprovider,andmakesthefinaldecisionherself.Shereturnstotheprovidertoswitchmethodsifthechosenmethoddoesn’tworkforher.

Femalefamilyplanningcurrentusers

Sheiscurrentlyusingamethodofcontraception(traditionalormodern),thoughitmaynotbethebestfitforherbodyorlifestyle.Sheishavingtroubleusingthemethodcorrectlyorexperiencingsideeffectsorwouldlikealong-actingorpermanentmethodbutisunsurewhatwouldworkbetterforherorhowtotalkwithaprovideraboutmethodexperiencesorswitchingmethods,andisthinkingaboutdiscontinuinghercurrentmethod.Shehasdiscussedfamilyplanningwithherpartnerbefore,butfindsitdifficulttotalkwithhimabouttheproblemssheishavingnowandwhatsheortheycoulddodifferentlytoavoidpregnancy.Sheisquietwithauthorityfigures,sincethatiswhatisoftenexpectedofwomenandbecausethelasttimeshewasattheFPclinictheproviderdidn’tseemopentoherquestions.Sheisusedtolettingdoctors,midwivesandnursesmakeallthedecisionsasshethinkstheyknowbest.

Shebelievesthatshehasarighttoqualityfamilyplanningcounselingandfeelsconfidenttostartadiscussionaboutfamilyplanningwithaprovider.Shehasthoughtaboutherfertilitydesires,questionsandconcernsrelatedtohercurrentmethodorfamilyplanningingeneralbeforeseeingaprovider.Shehasalsotalkedwithherpartner,ifshehasone,aboutwhattheywantfortheirfutureandhowbirthspacingorlimitingandusingfamilyplanningcanhelpthemmeettheirgoals.Whenvisitingaprovider,shesharesherneeds,desiresandotherinformation–bothspontaneouslyandinresponsetotheprovider’squestions.Shecanadequatelydescribetheproblemssheishavingand/orthesideeffectssheisexperiencing,anddiscusspossiblealternativemethods,includingwhatmethodsshe’dbeabletousemoreeasilyandsideeffectsofothermethodssheisconsidering.Shealsoasksquestionsoftheproviderandseeksclarificationsasnecessary.Shebelievesthatthedecisionofwhetherornottocontinueusingfamilyplanningorwhethertoswitchmethodsisultimatelyherstomake,(aloneorwithherpartner),withsupportandguidancefromaprovider,andmakesthefinaldecisionherself


BeforeArchetype AfterArchetype

Malepartners

Hehasafemalepartnerandisinterestedinfamilyplanning,butisn’tsurewhathispartnerthinks,andhemayhaveconcernsorquestionsaboutfamilyplanning’seffectiveness,safetyandsideeffects,aswellasaboutsocialperceptionsofhispartnerassomeonewhousescontraceptionandabouthimasamanifpeoplefindouttheyaretryingtodelay/limitchildren.Hedoesnotknowwheretogetmoreinformationsincehealthtalksandothermediumsareusuallytargetedatwomen,andfindsitdifficulttodiscussitwithhispartnersincehebelievesdecisionsaboutwhatmethodoffamilyplanningtousetobea“woman’sissue.”Therefore,hefindsitdifficulttostarttheconversationwithhispartner.Heisusedtomakingallthedecisionsinthehouse,buthiswifeusuallytakescareofthingsforherhealthandthechildren,andhedoesn’tdomuchtosupportherinthosekindsofthings.

Hethinksthatfamilyplanningissafe,effectiveandacceptableandbelievesthatopendiscussionaboutitdemonstratescommitmenttotherelationship.Healsothinksthatmenshouldbeinvolvedinfamilyplanning,andthatitisacceptableformenthemselvestousefamilyplanningmethods.Hehastalkedwithhispartneraboutwhattheywantforthefutureandhowbirthspacingorlimitingandusingfamilyplanningcanhelpthemmeettheirgoals.Heencourageshispartnertospeakopenlyandhonestlywithaproviderandhelpshispartnerthinkthroughquestionsbeforeattendingacounselingsession.HeiswillingtogowithhispartnerforFPcounseling,ifthatiswhatshewants.Hebelievesthatmenandwomenshouldmakedecisionstogetheraboutwhetherornottousefamilyplanningandwhatmethodtouse,andprovidessupporttohispartnerindoingso.

SMARTCLIENT/COUPLEAPPROACH

ThroughouttheSmartClient/Coupletool,usersareintroducedto“smartskills,”that,whenpracticed,willhelpthembecomeinformed,empoweredandconfidentclients/couples.Thethreeskillsare:THINK,TALKandSHARE,andvariationsoftheseskillscomeupbefore,duringandaftercounseling,suchas:

• Beforecounseling,theyTHINKabouttheirfertilitydesires;explorepotentialfamilyplanningmethodsthatfittheirlifeandneeds;consideranyconcernsorquestionstheyhaveaboutstartingfamilyplanningorabouttheircurrentmethod;discussfertilitydesiresandfamilyplanningwiththeirpartner,ifapplicable,and/orwithfamilyandfriends;andareawareoftheirrightsforvoluntaryfamilyplanningandqualitycounseling.

• Duringcounseling,theyTALKandactivelyparticipateinthediscussionwiththeirprovider,raiseconcerns,openlyprovideinformationrequestedandasktheirownquestions.Theyalsomakethefinaldecision(aloneorwiththeirpartner)ofwhethertousefamilyplanning,whichmethodtouseandwhethertoswitchmethodsordiscontinueuseiftheyarecurrentusers.

• Aftercounseling,theyfeelconfidenttousethefamilyplanningmethodasintended,handlesideeffects,seekoutinformationtheyneed,continueusingthemethodaslongastheywanttoavoid/delaypregnancyormakethedecisiontoswitchtoanothermethod,andreturntotheproviderwithconcernsorquestions,tocontinuewithamethodortogetanothermethod.TheyaresatisfiedusersoffamilyplanningandSHAREandadvocatewiththeirfriendsandfamily.


Skillsarereinforcedthroughquizzes,whichaskquestionsspecificallyaboutskills.Inaddition,intheSmartClienttool,theSMSremindersaretypicallybasedonasmartskillintroducedinthecall.

KEYELEMENTSOFTHETOOLS

• Channel.ThetoolisdeliveredtomobilephoneswithIVRandsupportingSMS.IVRisanautomatedtelephoneinformationsystemthatspeakstothecallerwithacombinationoffixedvoicemenusanddataextractedfromdatabasesinrealtime.Thecallerrespondsbypressingdigitsonthenumerickeypadoftheirtelephone.IVRisusedbecauseitisaccessiblebyanyonewithamobilephone,regardlessofthetypeofphone,carrierorinternetconnection.Itisalsosuitableforallliteracylevelsandcanserveaudienceswhospeakdifferentlanguages.FortheSmartClient/Coupletestingandstudies,anIVRplatformfromVOTOMobilewasused,howevertherearemanydifferentprovidersofIVRplatformstochoosefrom(seePartFourforguidanceonpickingaplatform).

• Approach.ThetoolisbaseduponSocialLearningTheory,2whichpositsthatpeoplelearnfromeachotherthroughobservation,imitationandmodeling.TheSmartClient/Coupletoolthereforeusesfictionalrolemodels,whodemonstratethedesiredbehaviorsandbehaviorchangeprocessinadramaformat,aswellaspersonalstoriesandexamplesofsmartclientorsmartclientdialogues.Thisallowstheintendedaudiencetoobserveanaction,understanditsconsequencesandbecomemotivatedtorepeatandadoptit.Thegoalistoincreaseanindividual'slevelofconfidenceintheirability,orself-efficacy,totakeactionwhetherthatisdiscussingfamilyplanningwithapartner,askingaproviderquestionsorusingcontraceptivemethods.Whiledramaisacommonapproachusedinbehaviorchangecommunication,itisusuallydeliveredviatelevision,radioorcommunitytheatre.Thedigitalhealthtoolexploreshowdramacanbedeliveredtomobilephones(viaIVR),usingshorterandsimplerstorylinesandepisodeswhilemaintainingthefictionaldramastyle.

• Userenrollment.Aprogramcanenrollusersintwoways:uploadingcontactinformationtotheplatformorself-enrollment.Forexample,ifaservicedeliveryprogramalreadyhasaclientrosterandwantstoprovidethistooltotheirclients,theycanaskclientsdirectlyiftheywishtoenroll.Themobilephonetoolcanalsobepromoteddirectlytowomenandmenthroughpromotionalmaterialsinthecommunity,requestingthemtoself-enrollbytextingashortcodeor“flash”anumber.3

• Usercosts.Usercostswilldependonthecountrycontextandtechnologyplatformused.Ingeneral,IVRisfreetotheuserastheyonlyreceivecallsandSMSmessages.Throughareversebillingsetup,allcostsarethereforecoveredbytheprogram,howeverthiscangetcostlydependingonthenumberofusers.Aprogramcanalsoofferuserstheoptiontodialalocalnumbertoreceivecontentondemand,butshouldinformusersaboutanycoststomakethecall.DependingontheIVRplatformused,itmaybepossibletosetuptheplatformsothatuserspayanominalfeetolisten,thereforecoveringsomeofthecostsofthecalls.

• Settinguserpreferences.Whenusersenrollinthesystem,theyreceiveacallthatasksthemseveralquestions,theanswerstowhichwillbeusedtosetuserpreferencesinthetoolandalsotocollectdataforeachuser.Thetoolspecificallyasksfortheuser’ssexandpreferredlanguage,whichareusedtotailorthemessagesreceived.Itisalsopossibletoaskadditionalquestions,suchaswhethertheyarenewtofamilyplanningoracurrentuser,whatmethodtheyareusing,andiftheyare

2 Bandura,A.(1986).SocialFoundationsofThoughtandAction.EnglewoodCliffs,NY:Prentice-Hall.3“Flashing”isacommonpracticeinAfricawherebyausercallsanumberandhangsupquickly.Thereceiverthencallsthepersonbackathisorherownexpense.Throughoutthecontinentitisknownas“flashing,”“beeping,”“missedcall”or,inFrench-speakingareas,“bipage.”


marriedorinarelationship.Thisinformationcanbeusedforfurthertailoringandformonitoringandevaluation.

• Calls.Thetoolsconsistsof17IVRcalls4:aninitialscreeningcall,13regularcallsandthreequizzes.Allmessagesaredesignedtobefivetofifteenvoiceminutesinlength,dependingonuserselectionforoptionalcontent.IntheSmartClienttool,usersreceiveanSMSreminderaboutthekeymessagefromthepreviouscall.IntheSmartCoupletool,usersreceivean“SMSchallenge”withapromptintendedtoencouragecouplecommunication.

• Callformat.Eachcallconsistsoffive(orsix,forSmartCouple)typesofsegments.Thefirsttwosegmentsplayautomaticallywhenthecallstarts,afterwhichuserswillbepresentedwiththeoptionoflisteningtotheremainingsegments.Thesegmentsinclude:1. Briefwelcomeandintroductiontothestorybyfriendlyhostcharacters,afemaleandmale.2. Shortdrama,whichfollowsacastofcharactersovereachepisode.3. “Friend-to-friend”chats,inwhichthehost“friends”deliverfollow-upmessagesandtipsrelated

tothecoremessageandthedrama,andasktheuseraquizquestion.Somemessagesinthissegmentaretailoredformaleandfemaleusers,basedontheiruserpreferencessetonenrollmentortailoredtotheuserresponsetothequestion.

4. Personalstory.Thisisanoptionalsegment,requiringusersto“press1”tohearthecontent.Personalstories,toldbyfemalesandmales,expressdiverseexperienceswithfamilyplanningthatcorrespondtothekeymessageoftheepisode.

5. SampleDialogue,isanoptionalsegment,requiringusersto“press2”tohearthecontent.Sampledialoguesfeatureafriendlyproviderandaclient(oracouple),modelingwhattoexpectduringavisittoafamilyplanningclinicandhowtodiscussneeds,preferencesandconcerns.

6. Malepersonalstoryordialogue.ThisisanoptionalsegmentintheSmartCoupletool,requiringusersto“press3”tohearthecontent.Malepersonalstoriesmaybecomplementarytothefemalepersonalstories,justtoldfromtheperspectiveofthemalepartners,ortheymaybeuniquestoriesexpressingdiverseexperienceswithfamilyplanning.Afewcallsdonotofferpersonalstoriesbutsampledialogues,betweenahusbandandwifeorbetweenamanandprovider,areofferedinstead.

Threecallsareaquizonly–askingusersafewbriefquestionstoreinforcekeymessages,evaluateuserunderstandingofcontentandencourageuserengagement.

• Keymessages.Thetoolsaddressmessagesrelatedtosmartclientsthroughoutthefulldecision-makingandcommunicationprocessofconsidering,adoptingandcontinuingfamilyplanning.FollowingtheTHINK-TALK-SHAREapproach,themessagesfocusonthevisionofinformed,empoweredandconfidentclientsbefore,duringandafterfamilyplanningcounseling.Thefollowingtableoutlinesthekeymessagesdeliveredineachcall.

4 See“PartFour:AdaptationGuide”forsuggestionsregardingthenumberofcalls.


5http://m4rh.fhi360.org/

Call KeyMessage

1 Questionstoestablishbaselinelevelofconfidenceintalkingwithnursepriortouseofthetool

2 Introductionofthemobilephonetoolandimportanceofcouplecommunication

3 Couplecommunication,aboutfertilitydesiresandintentionsandaligningthemwithpersonal/familygoals.IntroducetheTHINK,TALK,SHARESmartClientapproach.

4 Supportivepartnersandjointdecision-making,includingwaysmalepartnerscantakeonresponsibilityforfamilyplanninguse(i.e.,supportingpartner,usingafamilyplanningmethod)

5 Findingafamilyplanningprovider

6 Exploringandchoosingafamilyplanningmethod(couldincludelinkstoadditionalmethodinformationavailableviam4RH5)

7 Preparingquestionsbeforetalkingwithnurse.Writethemdownandtaketotheclinic.

8 Quiz1:Summarizeandevaluateunderstandingof“smartskills”beforevisitingaprovider

9 Expressingfeelings,concernsandpreferenceswithaprovider

10 Recognizinganddealingwithproviderbias

11 Askingquestionsandseekingclarificationduringcounselingwithaprovider

12 Quiz2:Summarizeandevaluateunderstandingof“smartskills”duringfamilyplanningcounseling

13 Familyplanningmethodsideeffectsandoptiontoswitchmethods;supportivepartnerswhenusingfamilyplanning

14 Socialcommunicationandpersonaladvocacy

15 Talkingwithaprovideraboutproblemswithfamilyplanningmethods

16 Ongoingcouplecommunication

17 Quiz3:Summarizeandevaluateunderstandingof“smartskills”whenusingfamilyplanning;finallevelofconfidenceintalkingwithnurseafterusingthetool


• SMSreminders/challenges.FortheSmartClienttool,anSMSmessageissentaftereachcalltoremindusersaboutthe“smalldoableaction”(SDA)promotedineachepisode.AnSMSmessageissentouttousersoftheSmartCoupletoolaswell,butthemessageswereframedasa“challenge”totheusertotalkwiththeirpartneraboutakeymessageinthepreviouscall.

• Monitoringandevaluation.Averyshortsetofpre-test/post-testquestionsarebuiltintotheIVRscripts.Thesequestionsfocusonuseoffamilyplanningandconfidenceintalkingwithafamilyplanningprovider.Amorein-depthevaluationofthetoolisrecommendedwhenrolledoutatscale(forguidanceonmethodology,seeSmartClient/CoupleUserStudyreports).MostIVRplatformsofferbuilt-indashboardsforcollectingreal-timedataforongoingmonitoringofplatformfunctionalityandusage.AnevaluationcouldbeautomatedthroughtheIVRplatform,howeverifthisisdone,itisimportanttorememberthatlistenerswilllikelynotlistenforverylongamountsoftime(seereportsonUserStudiesforcalldurationsanddiscussionofdropoff).

TESTINGTHETOOLS

TheSmartClientandSmartCoupletoolsweredevelopedandtestedwithaudiencesinNigeriaandCoted’Ivoirethroughout2016and2017.

ThescriptswerefirstwritteninEnglishandthentranslatedintoHausaforthefirstroundofpretestinginKaduna,Nigeria.Duringfocusgroupdiscussions,femaleparticipantssharedfeedbackonthecontent–whetheritwasrealistic,acceptableandrelevant–aswellastheirthoughtsonthetooloverall.

Feedbackfromthepretestparticipantswasincorporatedintothetoolandthefullseriesofcallswasrecorded.AftercontentwasloadedontotheIVRplatform(VOTOMobile),HC3conductedaprototypetestofthetoolwithparticipantsusingtheirphonestounderstandlisteningpatterns,technicalissueswiththeplatformandreactionsaboutthecontentandaccessingthetool.Inaddition,in-depthinterviewswereconductedwithasub-setofparticipantstogainfurtherinsightsintotheirimpressionsandexperienceusingtheIVRtool.

ThissameprocesswasrepeatedinCoted’IvoirewiththecontenttranslatedintoFrenchwithchangestothenamesofthecharacters.Menwereaddedtothepretestingandprototypetestingtounderstandtheirperceptionsofthecontentandtheirexperiencewiththetool.

Andfinallyfollowingthecompletionofthepretestingandprototypetesting,UserStudieswerecarriedoutforbothtoolsinNigeria.Thesestudiesweredesignedtomeasuretheimpactofthetoolsonhowusersthink,feel,actandintendtoact,relatedtofamilyplanning(seeSmartClientandSmartCoupleUserStudyReportshere[https://healthcommcapacity.org/technical-areas/family-planning/smart-client-smart-couples/].


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smart client and smart couple: digital health tools to ......we envision that “smart clients”...

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