Let’s Text About Sex: A Mobile Phone Program Delivers Sexuality Education

Over the past decade, mobile phone ownership has soared in Sub-Saharan Africa, from only 12 subscriptions per 100 people in 2004 to 71 subscriptions in 2014. Youth under 30 are the most avid users of text messaging. While more young men own phones than do women, this gap is narrowing.

In Ghana, adolescent pregnancy rates remain intractably high, leading to infant and maternal deaths, perpetuating poverty, and forcing girls to leave school.

As a doctoral student at Harvard University, my thesis examined programs and policies to improve sexual and reproductive health (SRH). Before I began my doctoral work, I spent months working in Ghana on a professor’s project that used mobile phones to improve adherence to malaria medication. I decided to investigate whether I could take advantage of the accessibility, confidentiality, and user-friendliness of mobile phones to improve SRH among adolescent girls.

My team and I recruited 756 girls aged 14-24 from 34 secondary schools in Accra, Ghana. We then randomized them to take part in one of three 12-week programs:

  • Unidirectional – Girls received text messages once a week with information on reproductive anatomy, sexually transmitted infections, and use of male condoms, female condoms, birth control pills, and emergency contraception. The messages also debunked myths about pregnancy prevention.
  • Interactive – Girls were invited to play a free interactive texting game to earn airtime credit. Each week, participants received a text message quiz question about the same topics as above. When they responded, they immediately received a confirmation message stating whether they were correct. For correct answers, girls received airtime credit as a reward.
  • Comparison – Girls received messages about a different health topic: malaria.

Before beginning the programs, all girls were asked to complete a questionnaire in class that asked them about their knowledge of SRH; they completed it again after the program ended (at three months) and again a year after that.

Figure 1: Large improvements in knowledge for both the Unidirectional and Interactive text messaging programs

The study led to four important conclusions:

(1) Knowledge of SRH dramatically improved for both the Unidirectional and the Interactive groups, as compared to the comparison group.

At the start of the study, average knowledge for all three groups was about 30 percent. At three months, the Interactive program doubled girls’ knowledge to an average of 57 percent, and the Unidirectional program increased knowledge to 44 percent. The comparison group didn’t change, remaining at only 33 percent.

(2) Engaging with the quiz made a big impact on how much participants learned through the texting program.

Despite providing the same informational content to participants, the Interactive program was more than twice as effective as the Unidirectional program.

(3) Girls retained the information they learned even a year later.

Knowledge scores remained steady at 54 percent in the Interactive and 45 percent in the Unidirectional. The comparison group did catch up over time, most likely due to information learned from other sources—such as the media—and from a short nurse-led session we provided to all participants after the three-month follow-up as a benefit for participating in our study.

(4) The impact of the programs on health are encouraging, but more research is needed.

While we found no impact on pregnancy rates in the full sample of girls, we found both programs reduced risk of pregnancy among girls reporting to be sexually active. However, only about one-third of participants were sexually active, so investigating these effects in the long-run is necessary to get a clear picture of the health impact.

These early results are promising; however, an important consideration is how to best scale-up and integrate such a program within existing comprehensive sexuality education (CSE) frameworks.

An unexpected experience at a media event I organized in Accra made me think more about the importance of understanding the local context and reaching out to decision-makers. Although I had received permission from the Ghana Education Service (GES) to conduct my study in schools, during the event a heated debate with the GES staff ensued about whether adolescents should be taught about condoms at all. They also expressed concern about the reaction from parents if such a program were integrated within schools. Representatives from the Ghana Health Service, local NGOs, and academics responded in support of CSE and the mobile health approach. The experience pointed to the on-going challenge of instituting CSE and the importance of continual dialogue between researchers and policymakers.

In focus groups I conducted after the study was completed, girls were very positive about the text messaging program, but reported feeling pressured to have sex and that the cost of contraceptives was a barrier. Going forward, I will explore ways I can improve my text messaging program to address these barriers.

As access to mobile phones increases every day, exploring how we can leverage this technology to improve health is essential. Integrating an innovative mobile phone program into CSE toolkits could be an effective way for Ghana and other countries in the Global South to make progress on reducing infant and maternal mortality, keeping girls in school, and securing a healthy future for the next generation.

Slawa Rokicki

Slawa Rokicki

Geary Institute for Public Policy, University College, Dublin

Slawa Rokicki is a Post-Doctoral Fellow at the Geary Institute for Public Policy at University College Dublin. She received her PhD from Harvard University in 2016. Her research interests are in adolescent sexual and reproductive health as well as maternal and child health. @slawarokicki

4 responses to “Let’s Text About Sex: A Mobile Phone Program Delivers Sexuality Education

  1. Am really touched with the innovation and I think if effectively applied will solve the existing gap or adolescent not receiving actual facts regarding SRH

    1. Thanks for your comment. I agree that expanding this program to boys is important, and I hope to do so in my future research. This work was done with a small student grant, so keeping it narrowly focused was necessary at this stage.

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