We conducted a mobile phone-based health promotion with women who are sex workers in Mombasa, Kenya, to reduce unintended pregnancy.
WHISPER is a mobile phone-based health promotion (mHealth) intervention in which text messages were sent to women who are sex workers in Mombasa, Kenya. The messages addressed pregnancy prevention and other sexual and reproductive health (SRH) topics, including HIV prevention, STI prevention and gender based violence, to improve sex workers' knowledge and support them to adopt healthier behaviours.
The intervention was tested in a randomised controlled trial to determine whether it resulted in fewer unintended pregnancies.
The participants receiving the WHISPER messages were compared to a second group receiving messages about nutritional health (the SHOUT intervention). Topics included:
The aim was to improve nutrition and reduce iron deficiency anaemia, and the rate of anaemia was compared between the SHOUT and WHISPER groups. In other words, each intervention was the equal attention control group for the other.
The messages for both groups were based on health promotion theory and consultation with women who are sex workers in Mombasa to make them relevant, engaging and effective. As well as simple standalone texts, participants received stories about sex workers in similar circumstances, overcoming familiar challenges and barriers in order to change their behaviour—for example, by using more effective long-term contraceptive methods or eating a greater diversity of fresh foods. Participants were also able to text into the system to request further information via automated response codes, without bearing the cost.
The project was a collaboration between the International Centre for Reproductive Health (ICRH, Kenya) and Burnet Institute, along with collaborating investigators from other institutions. ICRH is a local non-government organisation with a long history of providing services and support to sex workers via outreach and drop-in clinics in Mombasa, including STI testing, HIV testing, pregnancy testing, counselling and support for sexual and gender-based violence. ICRH has a respected role in the sex work community in Mombasa, and close links with other local community-based organisations working with female sex workers.
Reducing unmet need for contraception could prevent 54 million unintended pregnancies, result in 26 million fewer (often unsafe) abortions, and prevent 79,000 maternal and 600,000 newborn deaths globally each year. Female sex workers in Africa carry a markedly disproportionate burden of reproductive health morbidities, experiencing considerable unmet need for family planning and high incidence of unintended pregnancy.
In Kenya, our previous longitudinal research showed over one quarter (27%) of female sex workers have an unintended pregnancy each year. mHealth (mobile phone health) interventions are increasingly recognised for their enormous potential to reach large numbers of people across diverse populations segments and provide sustainable population-level platforms for preventive health in resource-constrained settings.
Our previous trials in Australia showed mHealth interventions significantly increased sexual and reproductive health knowledge and service uptake. Moreover, recent formative research among female sex workers in Kenya demonstrated high mobile phone use and ownership, and high levels of acceptability to receive health messages by text.
To assess the effectiveness of a 12-month mobile phone-based sexual and reproductive health promotion intervention to reduce the incidence of unintended pregnancy among female sex workers in Kenya. The primary outcome is the incidence of unintended pregnancy over 12 months of follow-up.
Female sex workers exposed to the sexual and reproductive health promotion intervention will experience fewer unintended pregnancies compared to female sex workers exposed to the nutrition intervention.
To assess the effectiveness of a 12-month mobile phone-based nutritional health promotion intervention on nutritional status among female sex workers in Kenya. The primary outcome is the prevalence of anaemia (haemoglobin less than 10.0 g/dL) among study participants at month 12.
Female sex workers exposed to the mobile phone-based nutrition intervention (SHOUT) will experience lower rates of anaemia than female sex workers exposed to the sexual and reproductive health intervention.
Enrolment for the WHISPER trial is due to commence in July 2016, with follow up to be completed by November 2017.
The study has 2 phases:
Phase 1 is due to be completed in May 2016. The research team has been working with female sex workers in Mombasa, Kenya, to develop and test the mobile health intervention and control packages. Six participatory message development workshops have been conducted with female sex workers for both sexual and reproductive health and nutrition messages, and the intervention modified accordingly. One-on-one interviews are being held with female sex workers to test the near-final message content and usability of the mobile phone platform.
Phase 2 will commence in July 2016. We will conduct a cluster randomised controlled trial to assess the effectiveness of our SMS-based interventions. Eligible women will be recruited from sex work venues (our clusters) by well-established peer outreach workers. Female sex workers will be randomised to the sexual and reproductive health or nutrition intervention (equal-attention control), with assessments done at baseline, 6, and 12 months follow-up.
Semi-structured face-to-face interviews will be conducted by trained research assistants at baseline, 6, and 12 months in a dedicated research space at two local drop-in centres linked to health facilities.
The primary study outcome for WHISPER is the incidence of unintended pregnancy over 12 months of follow-up. An unintended pregnancy is defined as one that is mistimed, unplanned, or unwanted at the time of conception. A psychometrically-validated 6-item questionnaire (London Measure of Unintended Pregnancy) is used to score pregnancy intention. Women will be asked about pregnancy intentions (self-reported and before any pregnancy occurred) at baseline, 6 and 12 months.
Secondary outcomes include the proportion of female sex workers using modern contraceptive methods and condoms consistently (dual protection); proportion using long-acting reversible contraceptive methods or injectable contraceptives; incidence of HIV and self-reported abortion, and the median score in contraceptive knowledge.
The primary study outcome for SHOUT is the prevalence of anaemia at 12 months of follow-up. Secondary outcomes include mean haemoglobin levels, proportion of FSWs with malnutrition, either underweight (BMI < 18.5kg/m2) or overweight (BMI ≥25 kg/m2), and the proportion reporting nutritious diet, and median score in nutrition knowledge.
If shown to be effective in this trial, mHealth interventions could be incorporated into broader sexual and reproductive health and/or nutrition strategies for female sex workers in Kenya and elsewhere, and has the potential to be scaled up for use with other women at a population level at low cost.