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Increasing Contraception Use with Mobile Phone- Based Interventions Smith, C (2017) Increasing contraception use with mobile phone- based interventions. PhD (research paper style) thesis, London School of Hygiene & Tropical Medicine. DOI: https://doi.org/10.17037/PUBS.03894556 Downloaded from: http://researchonline.lshtm.ac.uk/3894556/ DOI: 10.17037/PUBS.03894556 Usage Guidelines Please refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna- tively contact [email protected]. Available under license: http://creativecommons.org/licenses/by-nc-nd/2.5/ Increasing contraception use with mobile phone-based interventions Chris Smith Thesis submitted in accordance with the requirements for the degree of Doctor of Philosophy, University of London 2017 Supervisor: Caroline Free Department of Population Health Faculty of Epidemiology and Population Health London School of Hygiene and Tropical Medicine Funded by Marie Stopes International Innovation fund and UK Medical Research Council Declaration I, Chris Smith, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indication in the thesis. I have read and understood the School’s definition of plagiarism and cheating given in the Research Degrees Handbook. I declare that this thesis is my own work, and that I have acknowledged all results and quotations from the published or unpublished work of other people. I have read and understood the School’s definition and policy on the use of third parties (either paid or unpaid) who have contributed to the preparation of this thesis by providing copy editing and, or, proof reading services. I declare that no changes to the intellectual content or substance of this thesis were made as a result of this advice, and, that I have fully acknowledged all such contributions. I have exercised reasonable care to ensure that the work is original and does not to the best of my knowledge break any UK law or infringe any third party’s copyright or other intellectual property right. Name: Chris Smith Student ID: LSH237798 Signed: Dated: 11th November 2016 2 Abstract Background Interventions delivered by mobile phone have been demonstrated to be effective in other health areas. This thesis focuses on interventions delivered by mobile phone to increase contraception use. Methods This thesis comprises a systematic review, development and evaluation of the MObile Technology for Improved Family Planning (MOTIF) intervention to support post- abortion contraception in Cambodia with randomised controlled trial, and a mixed methods process evaluation. Results The systematic review identified five trials, two of which increased self-reported contraception use, one in the USA and the MOTIF trial in Cambodia (four-month data only). A meta-analysis was not possible due to differing interventions and outcome measures. Development of the MOTIF intervention involved literature reviews on determinants of contraceptive use, interviews and focus groups with women seeking abortion services in Cambodia. The intervention comprised six interactive voice messages with counsellor support depending on the response to the message. The intervention was associated with increased self-reported use of effective contraception at four months post-abortion (64% vs. 46%; Risk Ratio (RR): 1.39; 95% Confidence Interval (CI): 1.17–1.66) but not at 12 months (50% versus 43%; RR: 1.16; 95% CI: 0.92–1.47). Long-acting contraception use (intrauterine device, implant, 3 permanent method) was increased at four and 12 months. There was no significant difference in repeat pregnancies or abortions at four or 12 months. The intervention effect was primarily due to increased initiation of long-acting contraception. The majority of women were positive about the intervention which provided support for physical and emotional issues in addition to contraception use. The intervention could be implemented in current form, however cost-effectiveness data is lacking. The intervention could potentially be improved and further evaluated. Conclusions Interventions delivered by mobile phone can increase contraception use, but the evidence to date is mixed. Further trials of interventions delivered by mobile phone to increase contraception use are required. 4 Acknowledgements This study was possible because of support from many people and organisations. Foremost, I would like to thank Caroline Free for agreeing to be my supervisor, for her patience, guidance, mentorship, friendship and invaluable advice throughout every stage of my PhD. I particular appreciate that Cari took the time to provide detailed feedback on my work and was able to visit the project in Cambodia during the final stages of the intervention development prior to starting the trial. I would also like to thank my advisory committee for their input. Thoai Ngo has provided invaluable input into this study from the outset when he was head of research at Marie Stopes International, was instrumental in helping to obtain funding for the trial, and provided input to subsequent papers. I would like to thank Phil Edwards for his advice on statistics and input on the trial design and analysis. I would also like to thank John Cairns for his input into the cost-effectiveness analysis which will be a separate publication. I am very appreciative of the support received from different organisations, especially Marie Stopes International (MSI), the London School of Hygiene and Tropical Medicine (LSHTM), Imperial College London, the Medical Research Council (MRC) and InSTEDD, our tech partner. I would like to thank Judy Gold who was working for the Innovation and Best Practice team at Marie Stopes and supported funding of the trial from the MSI Innovation fund. Without this support the study would never have happened. Judy also provided input on the Cochrane review and intervention development. This project has spanned the tenures of three country directors at Marie Stopes International Cambodia (MSIC). I would like to thank Che Katz for finding the time to 5 meet with me when I visited Cambodia with a vague idea for a project in January 2012, Stefanie Wallach who was the country director during the Innovation fund period for giving the MOTIF team a dedicated office and joining for meetings with the Ministry of Health to obtain approval for the project, and the current country director Michelle Phillips for her support regarding continued implementation of the intervention, involving me with other mHealth initiatives at MSIC and still feel part of the MSIC family during my return visits. I was incredibly lucky to have an amazing local team to work with on the MOTIF project in Cambodia. In particular I would like to thank UK Vannak, the project manager, for her ideas, organisation, hard work and dedication performing both administrative and research roles. To develop an intervention and organise a multisite randomised controlled trial, complete four month follow up and conduct process evaluation interviews in 16 months with a small budget with money to spare is testament to her organisational skills. Particular thanks also goes to Ly Sokhey, the counsellor, who gave valuable input into the intervention development and evaluation, and delivered most of the intervention and trained another excellent counsellor, Sieklot Chinn. I would like to thank the research assistants Sras Thorng, Mao Thyda, Teav Socheat, and Chanroeun Tola, and Chhour Mollika who recruited participants from the four study clinics and conducted trial follow up. I would like to thank all of the staff at the four study clinics for their support, hospitality, and assisting with trial recruitment. In addition, I would like to thank all of the following people who contributed to the study in some way: Channe Suy and her team at the InSTEDD iLab South East Asia for their support in delivering the intervention, Melissa Cockcroft (MSIC) for her support 6 for the Innovation fund application and enthusiasm and involvement in the project, Prakash Nellapali (MSIC) for helping with the Innovation fund application, Thou Chum and Antoinette Pirie (MSIC) for assisting with Cambodia ethics approvals, Tung Rathavy (Reproductive Health National Programme Manager) for approving the project, Jerker Liljestrand (University Research Co., Cambodia) who provided insights on the reproductive health context in Cambodia, Kelly L’Engle (Family Health International) for her input on mobile phone-based interventions in low-income settings, John Cleland (LSHTM) for his input on the early project development, Azeem Majeed (Imperial College London) for support during my time at Imperial College during early project development, Anna Glasier (University of Edinburgh) for advice on assessing contraception use, Deborah Constant (University of Cape Town) for sharing details of the mAssist study in South Africa, Richard Lester and Mia Van der Kop for sharing details of the WelTel study in Kenya, Javier Sola (Open Institute, Cambodia) and Colin Spurway at BBC Media Action Cambodia for discussions on mHealth interventions in Cambodia, Chris Vickery (University Research Co., Cambodia) for facilitating my presentation at the World Health Organization (WHO) health partners meeting, Isolde Birdthistle (LSHTM) for feedback on the MSI ethics application and examining my PhD upgrade, Susannah Mayhew (LSHTM) for feedback on the MSI ethics application, Richard Hayes (LSHTM) for examining my PhD upgrade and providing input to the updated trial protocol, Ona McCarthy (LSHTM) for doing
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