Protocol Assignment Forum: Tools

A. Describe one tool that you will employ in your intervention strategy using the following domains....

1. Tool—type: Texting messaging and Hotline
2. Target Population:   Women in Nairobi, Kenya using contraception
3. Target Behavior: Seek help from healthcare providers in about side effects instead of discontinuing 
4. PRECEDE Category: Reinforcing
5. Platform: Ecomobile, Marketing texting platform

B. For a multi-tool intervention strategy, use the PER worksheet attached to describe how you will address each of the PRECEDE framework components (Predisposing, Enabling and Reinforcing). You may download this PER worksheet and/or copy/paste.

Previous Protocols: 

Protocol 1

A. What evidence are you proposing to translate into practice? There is new evidence that shows mobile health initiatives improve clinic attendance and family planning knowledge. I would like to use this as base to implement a mhealth program promoting continuation of family planning method chosen during the first postpartum year. The intervention will include a series of messages sent after a patient has chosen and used a specific method. The messages will contian information about side effects and a mechanism to reach out healthcare providers to ask more questions. 

1. Justify that this evidence is “ready for translation.” We have piloted a series of mobile messages about postpartum family planning, which was well received by our clients. There are also multiple other RCTs which shows that mobile health is a promising intervention for behavior change. 

2. Identify a single, key behavior change target for your translational activity. A common reason for discontinuation of family planning is the unexpected side effects. Patients say that they do not consult a healthcare provider because they were not told what to expect and imagine that their is something wrong with their reaction to the new method. With this intervention, we would like our patients to contact health care providers about side effects instead of discontinuing without consultation. 

3. Conduct a “gap analysis” of your target behavior. Look to diverse sources for “best guess” estimates if specific measures are not available. There isn't any evidence that shows how often a women returns for information about side effects, but other indicators could include return for follow-up visit or continuation of method at 1 month, 3 month and 6 months.

 B. What is the quality (performance) gap? The leading quality framework for family planning programs identifies proper information and education and good interpersonal relations as two key factors in providing high quality care. Communication about side effects is the most important piece of counseling that seems to be falling through the cracks. A recent study at UCSF showed that less than 50% of healthcare providers discussed side effects while counseling women about starting method. 

C. What is the outcome gap? As estimate of about 19% of women with an unmet need were users who discontinued used. About 30%worldwide of women discontinue their method due to side effects. 

D. Is there evidence that changing performance will improve health (clinical outcomes)? There is substantial evidence that shows improvement in quality of family planning decreases discontinuation after choosing and starting a method. A recent analysis showed that nearly 35% of unmet need for family planning can be met by providing support to women who have already started a method (Askew 2013). Furthermore, counseling about side effects decreases discontinuation by nearly 30% (Lei 1996).

Protocol 2

1. Define the communit(ies) for your project and explain why each is a stakeholder for your study. 

Technology Manager- The technology manager will be overseeing the distribution of family planning SMSes and with the texting platform and short code to which clients will respond. This person or team has to help design the logistics of the technology and make sure that it runs smoothly.

Healthcare Providers - Community Healthcare Workers and Nurses will be the professionals who are administering the care and managing client reponses and feedback. The system should be easy for them to use.

Patients - Patients are the main stakeholders in this program because they are receiving the support text messages. If the program and messages are not relevant and acceptable to them, the intervention will not work. 

2. Describe your plan for approaching potential community partners to ask for their involvement.

We have conducted multiple focus groups and individual interviews with postpartum mothers and community leaders to understand what their family planning needs. We have created the messages in response to their needs, the side effects they experience, and the questions that they have about family planning. We pre-tested the messages in the field with non-clients to assess for general acceptability. 

We have developed the SMS program with the help of the nurses and administration at the hospital so that we can make sure that the logistics are feasible and reasonable within the constraints of the normal functioning of the hospital. 

3. Identify which stages of your project you'll incorporate community input, and describe what types of input you'll solicit.

During the pilot of the project we will be recording the response rate and the questions that women call back with. This will help to assess how we should alter messages and possibly change our mode of outreach so that more women can receive support for continuation of family planning. We can analyze the demographics of the patients who respond to the messages and patients who do not, and possibly call a small sample of both sets so that we can receive more feedback and what works and what doesn't.

4. Name three ways you plan to share your results, beyond writing an academic article or presenting at an academic conference.

We are working with Women Deliver, an international advocacy organization for maternal health, to spread the programmatic results to help other hospitals reach out to their communities. 

We are also considering organizing a "chief's day" to disseminate the family planning statistics and delivery statistics of the communities we are serving. Providing tours of facilities and presenting statistics about uptake of family planning to leaders in the community  has proven effective in other similar settings to increase the use of long acting contraceptive methods.  

Protocol 3

1. Identify a patient or community group that contributes to or is involved in the principal behavior you are attempting to improve with your intervention.

My intervention is meant to support women who have chosen a method of contraception and have started to use a method. 

2. Using any of the individual explanatory theories in “Theory at a Glance”, develop an explanatory model for the target behavior (above) that you will be attempting to influence with your intervention.  This can be an extension/based on expected findings (or previously published literature) from your answers to Homework #3.  Figures are always very useful... keep it simple.

1. I can apply many of the other models of health behavior to the process leading up to choosing a method. For example, the elements of theory of planned behavior and diffusion of innovations theory contain concepts such as subjective norm and observability that can lead to the decision to use contraception and selection of a particular method. However, after choosing method, the stages of behavior change model fits the best because most women are in the action --> maintenance stage of behavior change. Please see figure attached. 

3. Identify how one or more of your specific interventions will target one or more of these key factors contributing to the behavior of interest.

Interventions are written in red. The intervention that I propose to improve maintenance of new behavior is a text messaging system in which patients are supported with messages that come directly to their phone about common side effects. This intervention will support women with the most common reason for discontinuation. Another intervention could include better counseling about expected side effects during administration of choose method. 

4. Create a framework that draws upon a socio-ecological framework to orient your target behavior within a larger context.  ie, what are some of broader, external forces that influence the individual behavior of interest...see Figure 2 of “Theory at a Glance.”

Pathophysiological pathways- Hormonal effects on mood, bleeding, appetite, nausea

Individual risk factors- Does not know what to expect about side effects of methods, not literate or able to read brochures or patient education given about methods, young and not able to talk about contraceptives with friends and family due to social stigma

Social Relationships- Women hear rumors about side effects and consequences for body, not enough reliable information about side effects, not able to talk openly about contraceptives

Institutions- Nurses are not trained to counsel about side effects, nurses and other health workers have their own preconceptions about side effects and effects of contraceptives on the body. 

Protocol 4

1. Describe the organizational and/or delivery system environment in which your intervention will take place.

The family planning text message intervention will take place in a technological space in between the clinic and the patient's home. This environment of this space includes the technological capabilities of our hospital, the familiarity with the technology of the healthcare providers and the familiarity of the technology of the patients.  We are currently using the text messaging technology for marketing purposes and have not yet used this platform to deliver clinical services. Therefore, the tech manager does not interact with text messages with urgency and privacy. The protocol around handling these text messages may need to be clearly delineated so that we handle clinical information appropriately. Furthermore, clinicians are not used to counseling about family planning over the phone, so we may to address some of the differences in phone counseling and in person counseling at the beginning of the intervention. Lastly, patients may not be used to receiving clinical information through their phone, so this might be a significant barrier to uptake of this service. 

2. Based on Shortell’s 4 domains of organizational change, identify organizational barriers that could potentially impede successful implementation of your proposed intervention.

a. Clinical Quality Performance
Quality in family planning counseling is difficult to achieve. We have standardized this through using balanced counseling cards and visual aids to help healthcare providers deliver high quality counseling. Over the phone, visual aids is not possible. 

We are planning to use community health workers to respond to questions about family planning use. We need a referall mechanism to make sure that these CHWs have the support they need if they are unable to answer specific questions

b. Patient Satisfaction

We might not be able to receive feedback from patients about this service because it is outside of the clinic and we will only be interacting with patients who call back, who are most likely to be satisfied with the service. 

c. Organizational Learning

Because the intervention is outside of the clinic, we may not be able to collect feedback about our messages, why women did not respond, what they thought about the message ect. This impedes our ability for organizational learning. 

Since the program will be implemented by lower level health workers, they might not feel they have the authority or control to discuss issues with the clinical protocol that need to be changed. 

d. Financial Performance

Using community health workers for counseling may save money initially, but we do not have a mechanism to assess the cost effectiveness of this intervention as it is an added service. Likely, the women who are calling for more information would not had contacted or used health worker time if this program did not exist. 

3. Using the same 4 domain model, describe how your intervention plan can take advantage of organizational strengths OR propose practical methods for addressing these barriers within your program.

a. Clinical Quality Performance
To address clinical quality, we will put together a specific protocol for counseling about family planning which the community health workers will not deviate. If they have extra questions, we will set up a protocol for referall to nurses. 

b. Patient Satisfaction

We need to construct a mechanism to contact patients who did not respond to the text messages. We currently have a patient satisfaction form through which we receive feedback about our clinical services. We also call patients after services to assess their satisfaction. We can incorporate questions about this new service in the satisfaction reports. 

c. Organizational Learning

We may be able to conduct focus groups or individual phone interviews with women who received messages to assess the acceptability of the intervention. We could ask about the message content and delivery system and look for factors that may prevent women from calling back or receiving the message at all. 

d. Financial Performance

We could measure the difference between continuation of family planning in intervention and non intervention group. Based on this data, we can figure out how much it costs for each woman who continued a method in the intervention group and decide whether this cost is worth it to the organization.