Project design and technology trade-offs for implementing a large-scale sexual and reproductive health mHealth intervention: Lessons from Sierra Leone

BACKGROUND: The Coronavirus 2019 (COVID-19) pandemic threatened decades of progress in sexual and reproductive health (SRH) and gender-based violence as attendance at health facilities plummeted and service uptake dwindled. Similarly, misinformation regarding COVID-19 was rife. The demographics in Sierra Leone are diverse in the education, economic, and rural/urban divide. Telecommunications coverage, phone ownership, and preference for information access medium also vary greatly in Sierra Leone. AIM: The aim of the intervention was to reach Sierra Leoneans at scale with information about SRH during the early stages of the COVID-19 pandemic. This paper presents the approach and insights from designing and implementing a large-scale mobile health (mHealth) messaging campaign. METHOD: Between April and July 2020, a cross-sectional multichannel SRH messaging campaign was designed and launched in Sierra Leone. Through a secondary analysis of project implementation documents and process evaluation of the messaging campaign report, the project design trade-offs and contextual factors for success were identified and documented. RESULT: A total of 1.16 million recorded calls were initiated and 35.46 million text messages (short message service, SMS) were sent to telecommunication subscribers through a two-phased campaign. In phase one, only 31% of the 1,093,606 automated calls to 290,000 subscribers were picked up, dropping significantly at 95% confidence level (p = 1) after each of the four weeks. In addition, the listening duration dropped by one-third when a message was repeated compared to the first 3 weeks. Lessons from phase one were used to design an SMS and radio campaign in the scale-up phase. Evidence from our analysis suggests that the successful scaling of mHealth interventions during a pandemic will benefit from formative research and depend on at least six factors, including the following: (1) the delivery channels’ selection strategy; (2) content development and scheduling; (3) the persona categorization of youths; (4) stakeholder collaboration strategies; (5) technology trade-offs; and (6) cost considerations. DISCUSSION AND CONCLUSION: The design and implementation of a large-scale messaging campaign is a complex endeavor that requires research, collaboration with other diverse stakeholders, and careful planning. Key success ingredients are the number of messages to be delivered, the format, cost considerations, and whether engagement is necessary. Lessons for similar low-and-middle-income countries are discussed.