Health services are often not designed to support women and girls to exercise their sexual and reproductive health rights fully. This is especially true for women in rural areas and in low- and middle-income countries. In Ethiopia, four out of five girls have a child by their twentieth birthday, before understanding the financial implications. PSI Ethiopia is seeking innovative, person-centered solutions to empower women, adolescent girls, young women, and couples to make free and informed decisions about their sexual and reproductive health.
In line with the Federal Ministry of Health’s (FMOH) prioritization of digital solutions, PSI-Ethiopia is digitizing Smart Start as part of the Global Affairs Canada-funded project Owning Their Future. Smart Start is a proven intervention developed using a human-centered design approach to counsel adolescent girls and young women (clients) and couples in Ethiopia about family planning. It is implemented through Smart Start Navigators (SSNs), who counsel clients and couples on financial and family planning. Clients interested in family planning will be referred to Health Extension Workers (HEWs) or Marie Stopes International (MSI) health providers for further family planning counseling and services, including the provision of contraceptive methods. Smart Start in digital format will engage clients in new and interactive ways and lay the foundation for the future expansion of digital health services in Ethiopia.
OBJECTIVE
The digital extension aims to identify and address the communication and operational challenges that health providers, community mobilizers — such as SSNs and HEWs — and clients face when interacting with Smart Start. Digitization offers the opportunity to deliver content interactively and engagingly, increase message consistency, and improve family planning counseling and pre-counseling to help clients and couples make informed and confident financial and family planning decisions.
User-Friendly Centered Design Approach
True to Smart Start’s roots, the Smart Start digital guide was developed based on insights from clients and couples who use reproductive health services and the healthcare providers who provide those services. The following insights informed our digital design:
- Clients have different counseling needs related to Smart Start – depending on their background, economic status, age, and desires.
- The quality of contraceptive counseling varies; thus, clients need more detailed information about family planning method side effects and their management.
- Clients want tailored family planning recommendations and/or decision support.
- Healthcare providers need a flexible tool that promotes dialogue and interaction and meets the diverse needs of their clients.
- Healthcare providers need a tool that makes their work easier, faster, and of higher quality.
Smart Start Digital Tool Prototypes and Learnings
Based on these insights, we quickly and inexpensively created low-fidelity prototypes with papers, simple videos, and sketches to create real-world scenarios to validate our hypothesis and test our ideas’ usability, appeal, and relevance with healthcare providers and clients. We learned that both healthcare providers and clients were satisfied with the idea of the digital Smart Start counseling tool and recommended the following:
- Visuals that show real-world scenarios, such as videos with testimonials, using real people instead of animations, etc.
- Simple visuals and interactions, minimal text.
- Audio options for all text content.
- Diverse characters and languages represent different cultural groups/regions.
- An interactive digital tool with games, quizzes, etc.
- Personalized counseling; the digital tools need to be flexible and adaptable to diverse types of clients to ensure that they receive relevant information.
- Frequent first-person prompts (in videos and voiceovers).
With these learning, we refined the Smart Start Digital Guide design concept and product development. The creative communication and app development team started developing Smart Start’s minimum viable product (MVP) with various screen designs, multi-media (video, animation, audio, etc.) content, a simple consumer-facing app, and analytics. After Smart Start MVP was developed, user acceptance testing was conducted to identify any challenges or required changes to app functionality, features, and contents. During this testing, we learned that:
- The healthcare providers were comfortable using the digital job aid except for some features, like technical and screen adjustments – preferring simplicity in design and navigation.
- Both the client and the healthcare provider like the fact that the visual, video, and audio content and tool was designed for a target audience regardless of literacy levels.
- The clients were very interactive and engaged during the digital counseling.
- They liked that it has an avatar representing the client and her family and prompts her individual needs and circumstances. Additional personalized family planning content helps girls leave the session feeling informed and confident.
- The clients like the app models positive husband behaviors and start a conversation on the importance of family planning with their husbands.
- The audio content enabled consistent counseling, as hoped.
- The clients were impressed by the music and the videos.
Smart Start 2.0
The Smart Start 2.0 app was created by combining all learnings from healthcare workers and client insights after multiple prototype testing and interactions. The final product offerings in full is laid out below.
Impact
The digital tool scored higher across all categories and among all data sources. The pilot results indicate that the digital tool is more engaging, interesting, informative, and desirable. Both clients and healthcare providers find it easier to use and report higher satisfaction levels. Use of the digital tool resulted in higher rates of method uptake than the manual Smart Start Counseling tool (74% vs. 64%)
Clients who received counseling with the digital Smart Start tool reported higher rates of understanding, had higher levels of unprompted recall, and reported higher levels of satisfaction than those who received counseling with the manual counseling tool. Furthermore, clients who received counseling with the digital tool also reported higher levels of confidence talking to their spouse about family planning and financial planning, and in their knowledge after the session.
The Smart Start Navigators who used the digital tool found it easier to use, were more confident using the tool, were more satisfied with the tool, found it easier to connect with clients, found it easier to deliver a consistent message, found it less complicated, and rated the quality of their counseling higher. When considering the client experience, SSNs who used the digital tool reported their tool being more engaging, memorable, and enjoyable to clients.
What is Next?
- Continuing to monitor use of the Smart Start digital counseling tool and make adaptations based on learnings and client feedback.
- Adding topics related to gender-based violence, safe abortion care, post-abortion care and COVID-19 to the digital health tools.
- Reaching 50,000 new clients through the Smart Start digital counseling tool.
For more information on the Smart Start tool and its impact in Ethiopia: https://a360learninghub.org/countries/ethiopia/
