As the body of evidence supporting mHealth continues to grow, so does the need for models to inform the scale-up and adaptation of successful interventions. FHI 360 has developed a unique adaptation model that is grounded in research utilization and communications science and literature. This framework was used to guide the initial m4RH pilot study in Kenya and Tanzania, and since then has been followed for developing expanded m4RH reproductive health messaging for Tanzania, and adapting the m4RH platform for comprehensive youth sexual and reproductive health programming in Rwanda, Uganda, and Tanzania. Beyond the m4RH program, the framework is relevant and informative for many initiatives that leverage social and digital media for health improvement.
To guide the process for adapting m4RH for new populations, settings, and content areas, FHI 360 developed a 10-step content adaptation and implementation framework (see next page). The framework is based on best practices for health communication theory, design, and implementation, and globally recognized adaptation and scale-up models. The framework incorporates iterative communication and testing with the target audience to identify their specific information needs and ensure content is tailored to meet their needs and effectively encourage healthy behavior.
Research shows that partners who are involved in the adaptation process from the beginning are more likely to support scale up, and that stakeholder engagement ensures the intervention is relevant, appropriate, feasible, and sustainable3,4. For example, the m4RH team established a technical working group (TWG) in each of the three youth adaptation countries to ensure the relevant stakeholders were engaged in the adaptation process. Members of the TWG assist in identifying key health issues for the priority population, provide technical review and input for program content, and contribute to partnerships to support the dissemination and roll-out of the mHealth program.
Conducting an assessment of the target audience’s varying information needs is a critical step in program adaptation. In each new setting, message content is selected through a careful review of literature on the information needs of the priority population, a review of existing global and local health curricula, and extensive input from members of the TWG. Consideration of information provided by existing behavior change communication programs and donor priorities is also a part of content development. In the case of m4RH, this has resulted in differences in program design and content across different countries and target populations. In its initial form, m4RH was designed as an automated, interactive, and on-demand SMS system; however, to increase user interaction and encourage additional behavior change, supportive messages in the form of locally relevant role model story narratives that demonstrate the benefits of healthy decision-making and behaviors have been developed and implemented in Rwanda, Uganda, and Tanzania. In Tanzania, supportive messages have also been developed in the form of weekly messages, in response to partner recommendations.
A key component of program adaptation is maintaining fidelity; when adapting an intervention it is imperative to ensure the key program elements, guiding behavioral theories, and internal logic are maintained5,6. When developing m4RH, FHI 360 applied a systematic approach to message development guided by best practices in health communication and behavior change theory. To ensure that new content maintains this strategic approach and internal logic, we mirrored this approach when developing new m4RH content.
Once all new content is developed, it should be presented to the TWG for review. This step helps to ensure that new program content meets all information needs determined through step two, and that new content is culturally appropriate. Content also should be reviewed by TWG members after step eight—immediately before the mHealth program is launched and promoted.
In order to ensure that the mobile phone messages and role model story narratives are clear, compelling, and contextually relevant, they are systematically tested via Focus Group Discussions (FGDs) with the priority population. If the target audience is youth, FGDs also should be conducted with parents and caregivers to ensure community acceptance of the youth mHealth program.
In each new setting or country, an appropriate technological partner must be identified to program and deploy the tailored system. m4RH primarily has partnered with Text to Change, a global non-profit technology company, for system deployment in East African countries.
Usability testing is a process in which potential users are asked to navigate through a live technological system, and are asked questions about the design, navigation, and use of the platform. After the m4RH system was programmed in each country and with new content, it was tested with the target population prior to launch. Usability testing is an essential step in technology program development and deployment to support robust user engagement and system access and adoption.
All user feedback gathered from content and usability testing is incorporated into the program before launch.
The integral partner relationships, established at the onset of program development, are essential for ensuring that the adapted program is promoted and available to all members of the priority population. Mass media promotion has been especially effective for m4RH adoption, with increased media buys and mentions showing a direct correspondence to increased use of the m4RH system.
By nature, mobile phone programs allow for continuous real time data collection. The m4RH platform is able to capture all system queries, or “hits,” through electronic and automatic logging. These hit data can be aggregated on a monthly, quarterly, or annual basis as needed—allowing for continuous monitoring and evaluation. Furthermore, m4RH has pioneered text data collection with users, showing that response rates in 5-question text surveys delivered two days after m4RH program access can approach 50% among all program users. Both closed- and open-ended questions are successfully fielded via text message, to obtain information on participant demographics, successful promotion methods, basic behaviors, and reasons for program use.
The m4RH adaptation process highlights the importance of local buy-in, government leadership, stakeholder involvement, and co-creation and testing with the target population and in all phases of the adaptation process, including the development and eventual launch of the mHealth system.
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