The Institute for Reproductive Health (IRH) at Georgetown University, has pioneered a new way to inform women of their fertility status using mobiles. IRH conducted proof of concept testing in India for an SMS-based delivery of the Standard Days Method (SDM) as an information based, low-cost and non-hormonal method of family planning.
SDM is a scientifically tested fertility awareness-based method that is recommended by WHO as a modern, natural family planning method. From the first day of menses, in a 26-32 day cycle, a woman’s most likely fertile days are from days 8 to 19. Avoiding intercourse during these days of the cycle has been tested to show up to 95% effectiveness against pregnancy.
Because of the high use of traditional methods for family planning, and the ubiquity of mobile phones, IRH thought of developing an innovative mobile platform for reproductive health called CycleTel™. Currently in pilot phase, women can subscribe to the service via SMS on the first day of the menses, after which, a text message is sent to her mobile indicating her fertility status as per the 8-19 day fertile window.
Previous field research in Lucknow, in the state of Uttar Pradesh, found that many women preferred a non-hormonal method or fertility awareness method for family planning. In the health survey in Uttar Pradesh, researchers found that approximately 14% of women were using a traditional method of family planning and many wanted to explore other options than the pill, IUD, condom or the rhythm method.
The Standard Day Method, a non-hormonal, periodic abstinence, information-based method of family planning, is increasing being adopted as the contraceptive method in developing countries, facilitated by a product called CycleBeads®. Cyclebeads is a string of different colored beads, in which each bead represents one day of the menstrual cycle. The first day of menses is represented by the red bead; the fertile days are white beads and; the days less likely to get pregnant are brown beads. A marker is moved each day of the cycle to indicate the fertile window. CycleTel is the mobile phone-based version of this existing fertility awareness product.
MobileActive.org spoke with Katherine Lavoie Cain, Program Officer of Research and Training at IRH about CycleTel to learn what inspired it to come about.
“With any commodity there are challenges. Although [Cyclobeads] are not expensive, the woman needs to get to the clinic or see a health worker to get the product. The Standard Days Method doesn’t actually require a commodity. It is information based. You don’t need to go your health care provider to get something. It’s not a clinical method.”
In the interest of increasing the availability of the SDM in developing countries, where there is high mobile penetration, IRH pioneered Cycletel using FrontlineSMS. Lavoie Cain said:
“In light of increase cell phone use in India, we thought why can’t we try using cell phones and text messaging as a way of informing women and couples of their fertile days. It is a different way of informing people of their fertile days… You have all these women who want to use a family planning method based on periodic abstinence, but they don’t know when their fertile window is, necessarily.”
Adopting CycleBeads into an SMS service, every month the woman has to send a text message to the Cycletel service on the first day of menses. The Cycletel system is designed to send users a message to let her know which days she can get pregnant. There is also a menu-based service, where women can choose from a set of options to receive more information via SMS about alternative family planning methods, STI/HIV prevention, counseling and testing information, condom use and connect to local health clinics. Additionally, a helpline number is available for one-on-one consultation over the phone.
The IRH conducted a proof of concept testing in Lucknow, where it studied the appropriateness of the technology, given the users and context, and included the input of target users to guide the development of the SMS service. The three phases included:
- Focus group discussions (n=54): to understand patterns of phone usage, determine potential interest among the target audience, and explore appropriate messaging and preferences for the service.
- Cognitive interviews (n=18): to verify the comprehension of messages and adapt messages as per input from users
- Manual testing (n=26): in which, married couples were enrolled for 2 cycles to assess CycleTel’s feasibility, user satisfaction and correct use.
Culturally specific preferences for reproductive messaging
From the preliminary results, the developers learned a lot about users’ preferences with respect to getting SMS messages about fertility. Non-technical messages and simple messages in a culturally appropriate way worked better.
For example, women did not appreciate receiving messages reading “fertile day” or “non-fertile day” nor “can” or “cannot” get pregnant, which were demeaning. Instead, they recommended that messages read as “safe” or “unsafe day”. This general, non-technical terminology also helped protect privacy, confidentiality, whether or not phones were individually owned or shared.
There was also a preference for messages only to be sent on unsafe days, and for minimal information to be sent about length of fertile window. Women preferred only receiving messages on their fertile days, not every single day.
Sending SMSs in “Hinglish” is the best way to go!
The research group realized that not all mobile phones support the Hindi script (Devanagari alphabet), but did not want to send out text messages in English, since Hindi is widely spoken and known in India.
Interestingly, women better understood messages written in “Hinglish”, which is the Hindi script written out in the Roman alphabet. The focus groups and cognitive interviews confirmed that "Hinglish" is the best way to ensure comprehension among users.
“Hinglish” also include full English words opposed to the Hindi word, which may not be easily understood. For instance, the words “natural” or “date” in English are better understood than the equivalent translations in Hindi.
Additionally, using pure Hindi in SMSs is not recommended. On unsafe days, messages read “Aaj asurakshat din hai”, which translates to, “Today is an unsafe day”. Using the term "unsafe day" was better understood than the word for “fertile day”, which is a more technical word.
Other interesting findings from Cycletel’s proof of concept testing in Lucknow:
- SMS was the preferred channel for receiving information about fertility status, instead of voice.
- Surprisingly, half of the males in the pilot felt that both partners should receive the fertility messages, especially since they bring the condoms home.
- Users recommended that the helpline number should be given out in the beginning, instead of later in the program.
- Women preferred responding to yes or no questions rather than entering key words like “red”, “date” or “agree”.
- Women preferred that messages were limited to 1 SMS, instead of being broken into 2 SMSs.
- Greetings, like “great”, “thank you”, confused participants and women did not know whether to answer or not. Often they thought they had to respond to every message they received.
Women are more accustomed to forwarding SMS rather than composing them
A total of 26 women used CycleTel as a fertility awareness method of family planning during the proof of concept. Although another 19 women completed admissions interviews, many remained non-users. In a follow-up with non-users, IRH found that often their womens’ mobiles were switched off. They also learned that there was incompatibility between the major mobile network operators Vodafone, Reliance and Airtel that impeded their use of the CycleTel service.
Though initially, SMS messaging was thought to be a common practice, IRH learned quickly that many women who own a mobile phone were not in fact in the habit of actually writing and sending SMSs. Instead, women more commonly were accustomed to forwarding SMS. Said Lavoie Cain:
“Just become someone has a phone, doesn’t mean they can send a text message. The educational level is not there. It makes it more difficult for them to compose a message. We were really hoping to reach women in rural areas, but in a lot of those areas, especially in northern India, you’re dealing with high illiteracy and those are definitely barriers.”
Given these literacy barriers, IRH may shift its target market to focus slightly more on people of middle to high income, instead of focusing on the poorest of the poor, at least for the moment.
Users are willing to pay 15-35 rupees/month for CycleTel
In India, the majority of health care expenses are paid for out-of-pocket. Men and women, who participated in Cycletel pilot test, were willing to pay for the service. In the focus group discussions, women suggested 20-25 rupees, men suggested 15 rupees and couples suggested 30-35 rupees as reasonable monthly price for CycleTel.
“[IRH] would like it to be a service that is not just something that’s supported by USAID, but that it can take off and be a part of the market on its own, delivered by cell phone companies. And they can at the very least break even with it.”
Such market based solutions for health that deliver valuable services, cheaply, have potential for sustainability. Everyone who used Cycletel in this pilot test wanted to continue after the 2 months trial and would recommend it to a friend.
Beyond the Proof-of-Concept
By the end of year, IRH hopes to begin another round of manual testing in Delhi (coming soon) and is looking to test Cycletel with 500 users in India after that. The next step will be to design the software and test it with a larger group of women.
For the pilot testing, IRH used FrontlineSMS to send out the text messages. For the CycleTel system, they would like the SMS alerts to be automated. For the next phase of CycleTel, the focus will be to develop an automated messaging system, so that the service could be available to users on a wider scale.
Lavoie Cain believes that CycleTel could work in many countries. IRH is interested in testing CycleTel in the Phillipines and Rwanda as well. The strategy forward will be to conduct proof of concept testing in each area they intend to launch. Said Lavoie Cain:
“In every country, we need to start in the beginning, because the messages are going to be unique to the setting. Each setting will have its own preferences and what works best in that setting.”
CycleTel's strategy is rooted in providing a culturally appropriate family planning service for women in developing countries. IRH has been able to accomplish this through a participatory approach in the design process, essentially developing a service that is directly influenced by users.
The CycleTel project is being carried out as part of the Fertility Awareness-based Methods (FAM) Project. This 5 year global project intends to scale modern natural FP methods (like SDM, and Lactational Amenorrhoea Method or LAM) in national level public and private programs in select countries. The FAM project is funded by USAID.
Family Planning through the Mobile Phone, No Doctor Necessary! Locations
The Institute for Reproductive Health (IRH) at Georgetown University, has pioneered a new way to inform women of their fertility status using mobiles. IRH conducted proof of concept testing in India for an SMS-based delivery of the Standard Days Method (SDM) as an information based, low-cost and non-hormonal method of family planning.
SDM is a scientifically tested fertility awareness-based method that is recommended by WHO as a modern, natural family planning method. From the first day of menses, in a 26-32 day cycle, a woman’s most likely fertile days are from days 8 to 19. Avoiding intercourse during these days of the cycle has been tested to show up to 95% effectiveness against pregnancy.
Because of the high use of traditional methods for family planning, and the ubiquity of mobile phones, IRH thought of developing an innovative mobile platform for reproductive health called CycleTel™. Currently in pilot phase, women can subscribe to the service via SMS on the first day of the menses, after which, a text message is sent to her mobile indicating her fertility status as per the 8-19 day fertile window.
Previous field research in Lucknow, in the state of Uttar Pradesh, found that many women preferred a non-hormonal method or fertility awareness method for family planning. In the health survey in Uttar Pradesh, researchers found that approximately 14% of women were using a traditional method of family planning and many wanted to explore other options than the pill, IUD, condom or the rhythm method.
The Standard Day Method, a non-hormonal, periodic abstinence, information-based method of family planning, is increasing being adopted as the contraceptive method in developing countries, facilitated by a product called CycleBeads®. Cyclebeads is a string of different colored beads, in which each bead represents one day of the menstrual cycle. The first day of menses is represented by the red bead; the fertile days are white beads and; the days less likely to get pregnant are brown beads. A marker is moved each day of the cycle to indicate the fertile window. CycleTel is the mobile phone-based version of this existing fertility awareness product.
MobileActive.org spoke with Katherine Lavoie Cain, Program Officer of Research and Training at IRH about CycleTel to learn what inspired it to come about.
“With any commodity there are challenges. Although [Cyclobeads] are not expensive, the woman needs to get to the clinic or see a health worker to get the product. The Standard Days Method doesn’t actually require a commodity. It is information based. You don’t need to go your health care provider to get something. It’s not a clinical method.”
In the interest of increasing the availability of the SDM in developing countries, where there is high mobile penetration, IRH pioneered Cycletel using FrontlineSMS. Lavoie Cain said:
“In light of increase cell phone use in India, we thought why can’t we try using cell phones and text messaging as a way of informing women and couples of their fertile days. It is a different way of informing people of their fertile days… You have all these women who want to use a family planning method based on periodic abstinence, but they don’t know when their fertile window is, necessarily.”
Adopting CycleBeads into an SMS service, every month the woman has to send a text message to the Cycletel service on the first day of menses. The Cycletel system is designed to send users a message to let her know which days she can get pregnant. There is also a menu-based service, where women can choose from a set of options to receive more information via SMS about alternative family planning methods, STI/HIV prevention, counseling and testing information, condom use and connect to local health clinics. Additionally, a helpline number is available for one-on-one consultation over the phone.
The IRH conducted a proof of concept testing in Lucknow, where it studied the appropriateness of the technology, given the users and context, and included the input of target users to guide the development of the SMS service. The three phases included:
- Focus group discussions (n=54): to understand patterns of phone usage, determine potential interest among the target audience, and explore appropriate messaging and preferences for the service.
- Cognitive interviews (n=18): to verify the comprehension of messages and adapt messages as per input from users
- Manual testing (n=26): in which, married couples were enrolled for 2 cycles to assess CycleTel’s feasibility, user satisfaction and correct use.
Culturally specific preferences for reproductive messaging
From the preliminary results, the developers learned a lot about users’ preferences with respect to getting SMS messages about fertility. Non-technical messages and simple messages in a culturally appropriate way worked better.
For example, women did not appreciate receiving messages reading “fertile day” or “non-fertile day” nor “can” or “cannot” get pregnant, which were demeaning. Instead, they recommended that messages read as “safe” or “unsafe day”. This general, non-technical terminology also helped protect privacy, confidentiality, whether or not phones were individually owned or shared.
There was also a preference for messages only to be sent on unsafe days, and for minimal information to be sent about length of fertile window. Women preferred only receiving messages on their fertile days, not every single day.
Sending SMSs in “Hinglish” is the best way to go!
The research group realized that not all mobile phones support the Hindi script (Devanagari alphabet), but did not want to send out text messages in English, since Hindi is widely spoken and known in India.
Interestingly, women better understood messages written in “Hinglish”, which is the Hindi script written out in the Roman alphabet. The focus groups and cognitive interviews confirmed that "Hinglish" is the best way to ensure comprehension among users.
“Hinglish” also include full English words opposed to the Hindi word, which may not be easily understood. For instance, the words “natural” or “date” in English are better understood than the equivalent translations in Hindi.
Additionally, using pure Hindi in SMSs is not recommended. On unsafe days, messages read “Aaj asurakshat din hai”, which translates to, “Today is an unsafe day”. Using the term "unsafe day" was better understood than the word for “fertile day”, which is a more technical word.
Other interesting findings from Cycletel’s proof of concept testing in Lucknow:
- SMS was the preferred channel for receiving information about fertility status, instead of voice.
- Surprisingly, half of the males in the pilot felt that both partners should receive the fertility messages, especially since they bring the condoms home.
- Users recommended that the helpline number should be given out in the beginning, instead of later in the program.
- Women preferred responding to yes or no questions rather than entering key words like “red”, “date” or “agree”.
- Women preferred that messages were limited to 1 SMS, instead of being broken into 2 SMSs.
- Greetings, like “great”, “thank you”, confused participants and women did not know whether to answer or not. Often they thought they had to respond to every message they received.
Women are more accustomed to forwarding SMS rather than composing them
A total of 26 women used CycleTel as a fertility awareness method of family planning during the proof of concept. Although another 19 women completed admissions interviews, many remained non-users. In a follow-up with non-users, IRH found that often their womens’ mobiles were switched off. They also learned that there was incompatibility between the major mobile network operators Vodafone, Reliance and Airtel that impeded their use of the CycleTel service.
Though initially, SMS messaging was thought to be a common practice, IRH learned quickly that many women who own a mobile phone were not in fact in the habit of actually writing and sending SMSs. Instead, women more commonly were accustomed to forwarding SMS. Said Lavoie Cain:
“Just become someone has a phone, doesn’t mean they can send a text message. The educational level is not there. It makes it more difficult for them to compose a message. We were really hoping to reach women in rural areas, but in a lot of those areas, especially in northern India, you’re dealing with high illiteracy and those are definitely barriers.”
Given these literacy barriers, IRH may shift its target market to focus slightly more on people of middle to high income, instead of focusing on the poorest of the poor, at least for the moment.
Users are willing to pay 15-35 rupees/month for CycleTel
In India, the majority of health care expenses are paid for out-of-pocket. Men and women, who participated in Cycletel pilot test, were willing to pay for the service. In the focus group discussions, women suggested 20-25 rupees, men suggested 15 rupees and couples suggested 30-35 rupees as reasonable monthly price for CycleTel.
“[IRH] would like it to be a service that is not just something that’s supported by USAID, but that it can take off and be a part of the market on its own, delivered by cell phone companies. And they can at the very least break even with it.”
Such market based solutions for health that deliver valuable services, cheaply, have potential for sustainability. Everyone who used Cycletel in this pilot test wanted to continue after the 2 months trial and would recommend it to a friend.
Beyond the Proof-of-Concept
By the end of year, IRH hopes to begin another round of manual testing in Delhi (coming soon) and is looking to test Cycletel with 500 users in India after that. The next step will be to design the software and test it with a larger group of women.
For the pilot testing, IRH used FrontlineSMS to send out the text messages. For the CycleTel system, they would like the SMS alerts to be automated. For the next phase of CycleTel, the focus will be to develop an automated messaging system, so that the service could be available to users on a wider scale.
Lavoie Cain believes that CycleTel could work in many countries. IRH is interested in testing CycleTel in the Phillipines and Rwanda as well. The strategy forward will be to conduct proof of concept testing in each area they intend to launch. Said Lavoie Cain:
“In every country, we need to start in the beginning, because the messages are going to be unique to the setting. Each setting will have its own preferences and what works best in that setting.”
CycleTel's strategy is rooted in providing a culturally appropriate family planning service for women in developing countries. IRH has been able to accomplish this through a participatory approach in the design process, essentially developing a service that is directly influenced by users.
The CycleTel project is being carried out as part of the Fertility Awareness-based Methods (FAM) Project. This 5 year global project intends to scale modern natural FP methods (like SDM, and Lactational Amenorrhoea Method or LAM) in national level public and private programs in select countries. The FAM project is funded by USAID.
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