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Female sex workers (FSWs) have high rates of both unintended pregnancy and HIV, but few health promotion interventions address their contraceptive needs or other sexual and reproductive health and rights (SRHR) concerns. A broader approach integrates contraceptive promotion with HIV and sexually transmitted infection (STI) prevention and management, alcohol awareness, gender-based violence and rights, and health care utilization. The Women’s Health Intervention using SMS for Preventing Pregnancy (WHISPER) mobile phone intervention uses a participatory development approach and behavior change theory to address these high-priority concerns of FSWs in Mombasa, Kenya.
This paper aimed to (1) describe the process of development of the WHISPER intervention, its theoretical framework, key content domains and strategies and (2) explore workshop participants’ responses to the proposed intervention, particularly with regard to message content, behavior change constructs, and feasibility and acceptability.
The research team worked closely with FSWs in two phases of intervention development. First, we drafted content for three different types of messages based on a review of the literature and behavior change theories. Second, we piloted the intervention by conducting six workshops with 42 FSWs to test and refine message content and 12 interviews to assess the technical performance of the intervention. Workshop data were thematically analyzed using a mixed deductive and inductive approach.
The intervention framework specified six SRHR domains that were viewed as highly relevant by FSWs. Reactions to intervention content revealed that social cognitive strategies to improve knowledge, outcome expectations, skills, and self-efficacy resonated well with workshop participants. Participants found the content empowering, and most said they would share the messages with others. The refined intervention was a 12-month SMS program consisting of informational and motivational messages, role model stories portraying behavior change among FSWs, and on-demand contraceptive information.
Our results highlight the need for health promotion interventions that incorporate broader components of SRHR, not only HIV prevention. Using a theory-based, participatory approach, we developed a digital health intervention that reflects the complex reality of FSWs’ lives and provides a feasible, acceptable approach for addressing SRHR concerns and needs. FSWs may benefit from health promotion interventions that provide relevant, actionable, and engaging content to support behavior change.
HIV prevention programs for female sex workers (FSWs) utilizing peer educators, drop-in-centers, and mobile outreach have been implemented in sub-Saharan Africa [
Pregnancy prevention is a particular area of need for FSWs, with high rates of unintended pregnancy and low uptake of highly effective contraception and dual method use among those wanting to avoid pregnancy [
Limited knowledge of long-acting reversible contraceptives (LARCs), fear of side effects, and social and gender norms that limit the use of family planning are common among FSWs in this setting [
Mobile phones have been used to deliver health promotion in a variety of contexts, and this approach has been effective in improving knowledge, use, and continuation of contraception [
We developed a mobile phone intervention for FSWs in Mombasa to promote contraceptive use—particularly LARCs—and other behaviors related to SRHR. This intervention, called the Women’s Health Intervention using SMS for Preventing Pregnancy (WHISPER), is being tested in a cluster-randomized controlled trial (RCT) to assess its impact on unintended pregnancy [
The intervention was developed using a participatory design approach. FSWs in Mombasa were involved in the initial conception of the intervention and in formal workshopping and testing. Participation by the target community in intervention design [
In this paper, we aim to (1) describe the development of the WHISPER intervention and present its theoretical framework, key content domains, and strategies, and (2) explore workshop participants’ responses to the proposed intervention, particularly with regard to message content and behavior change constructs. Finally, we present the schedule and approach for intervention implementation and delivery.
Methods for the development of WHISPER have been described by Ampt et al [
The framework for intervention content, and the drafting of initial messages, was informed by the following: review of the literature on motivators and barriers to FSWs’ adoption of healthy SRHR behaviors; consideration of health promotion theory, specifically transtheoretical [
A review of the literature and behavior change theory highlighted key content domains and corresponding behavioral factors that impact the risk of unintended pregnancy, STIs, and HIV.
These domains and factors were confirmed as important and relevant to FSWs during consultations with peer educators and were incorporated into a logic model (
The Women’s Health Intervention using SMS for Preventing Pregnancy program logic.
The intervention was designed to incorporate specific cognitive strategies from behavior change communication theory [
These messages provided specific information in less than 160 characters (1 standard SMS) and used strategies to motivate and educate participants. In the precontemplative stage, more of the messages aimed at the women were developed to be sent early in the intervention, with greater emphasis on action and maintenance later on. However, there was a mixture throughout, given the anticipated diversity of stages of change of participants. The sequencing of role model stories also reflected this approach. Push messages were delivered on alternating months to role model stories. Examples of push messages and their associated behavior change strategies are provided in
Example messages and a role model story episode mapped to behavior change theory and strategies.
Intervention domain | Example messagea | Stage of change and definition | Cognitive strategies | ||||
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Contraception | We have something important to tell you. Family planning lets you have sex without getting pregnant. That’s what WHISPER is all about. | Precontemplation: not yet thinking about changing behavior | Increase awareness of risk; set positive outcome expectations; attract attention, |
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Dual protection | Husband or boronga (type of client)? (No matter who they are, they should be wearing a condom if they want to be with you). Hugs and kisses from WHISPER. | Precontemplation | Improve knowledge; use a friendly and personal tone to provide positive encouragement and social support; use humor to highlight desired behavior | |||
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Contraception | Most women who use family planning continue to have a normal sex drive. If you find one method leaves you without a sexual appetite, there are many other options. | Contemplation and preparation: thinking about making changes in behavior | Improve knowledge; challenge outcome expectations (related to fears of side effects); address specific concerns; provide an alternative strategy | |||
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HIV and STIs | Did you know you can take a rapid test for HIV? You get the result straight away, so you don’t have to come back later! Reply 100 for services that do testing. | Contemplation and preparation | Set positive outcome expectations; motivate; provide specific action strategy | |||
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Gender-based violence, stigma, and rights | Violence against women is not ok, and it’s not your fault. If you experience violence, remember you are not alone and can get help. Hugs, WHISPER. | Contemplation and preparation | Change social norms and model empowerment; provide social support; build self-efficacy for getting help; encourage help-seeking behavior | |||
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Alcohol and drug use | You can reduce your drinking: ask for beer bottles filled with water, add water to mixed drinks, secretly dump some out, drink soda, drink slow. WHISPER. | Preparation and action: preparing to act or taking actions to change behavior | Build skills and self-efficacy by breaking down behavior into components; develop action plans; encourage goal setting | |||
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Service information and access | If you have a bad experience with a health care provider, don’t give up—ask your peer educator for clinic recommendations. Kisses and hugs. | Action and maintenance: taking actions to change behavior, for 6 months or more (maintenance) | Improve self-efficacy by overcoming setbacks; build skills to prevent or address relapse; provide alternative strategies | |||
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Contraception | Karibu tujienjoy [Welcome, let's have fun]! I’m Ciku from WHISPER. I’m new to town: I left my village because my husband drank a lot and was violent. I might be young, but I know I deserve better. I have some mpenzi [lovers] who help me out but I’ve had a couple of scares at the clinic, if you know what I mean. I need a better way to prevent pregnancy! | The character moving from precontemplation to contemplation in this episode. | Personalize, set scene; model self-efficacy and empowerment (leaving a violent relationship); present negative outcome expectations (risks of current behavior) |
aExample messages contain final content, including any modifications made during phase 2.
Role modeling healthy behaviors through stories about relatable peers constitute a recognized social-cognitive strategy for behavior change [
Role model stories developed from peer educator consultation.
Scenarios from FSWa peer educators | Character | Key LARCb method in story | Other content in the story |
Moving to the city to escape a violent husband and starting in sex work | Ciku | Implant | Intimate partner violence, inconsistent protection, pregnancy, and STI scares |
Main partner (husband or boyfriend) resisting the use of condoms and other contraception | Sandra | Implant | Part-time sex work, STI transmission from boyfriend, condom negotiation with boyfriend, contraceptive pill |
Pressure to drink alcohol before sex with a client, and resulting adverse consequences | Lynette | IUDc | Sexual risk-taking while intoxicated, strategies for reducing drinking. |
Experiencing unintended pregnancy, concern about side effects preventing the use of contraception | Olivia | IUD | Unintended pregnancy and fetal loss, rumors about different contraceptive methods |
Being arrested and unable to access emergency contraception | Mimi | IUD | Summary of different contraceptive methods from friends and peer educator |
Difficulty negotiating condom use with a client, and making assumptions about his STId or HIV status | Joslyn | Implant | Dual method use with clients, STI myths |
aFSW: female sex worker.
bLARC: long-acting reversible contraceptive.
cIUD: intrauterine device.
dSTI: sexually transmitted infection.
Previous research has indicated that messages about reproductive health that are accessible at any time via an on-demand menu are appealing and motivational to women in East Africa [
Example message providing a link to on-demand content, SMS codes, and corresponding on-demand messages.
Push message linking to on-demand menua and code to trigger message (sent via SMS) | Corresponding on-demand messagea | |
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11 | Implants are small rods placed under the skin of a woman’s arm. Highly effective for 3 to 5 years. It can be removed anytime. For married and singles. May cause light irregular bleeding. When removed, you can become pregnant with no delay. No infertility or birth defects. WHISPER main menu, reply 00. For more information, reply 12. |
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12 | Implants: Benefits 13, Side effects 14, Bleeding side effects 15, True facts 16, Insertion/Removal 17, WHISPER main menu 00. |
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15 | Implant bleeding side effects: Monthly bleeding may be lighter and irregular during the first year, then lighter, more regular, and infrequent. Monthly bleeding may stop for some women. If bleeding stops it is not harmful—blood does not build up inside the womb. |
aExample messages contain final content, including any modifications made during phase 2.
The second phase involved testing and refining draft messages based on detailed feedback from FSWs in 6 workshops and 12 interviews. A semistructured workshop guide covered responses to specific messages, overall feedback on the program, and preferences for program structure, timing, delivery, and vernacular. A female researcher who had experience working with FSWs was employed to moderate the workshops rather than an FSW peer educator because this provided more anonymity and privacy to participants. Also, experienced facilitating groups was considered necessary to cover content efficiently but in a sensitive way. A note-taker was also present.
Workshop participants were recruited through purposive sampling of sex work venues (
We modified the intervention based on the results of the workshops and tested it in 12 one-on-one interviews with participants who met the same eligibility criteria. Interviews tested the technical performance of the SMS system, reactions to the use of on-demand (
Workshops and interviews were audio-recorded, and detailed notes taken during the sessions were augmented with data from the recordings and translated into English, where necessary, by research assistants. A mixed deductive and inductive thematic approach to analysis was adopted [
Participants of both workshops and interviews provided written consent before proceeding. They were provided with refreshments and given 500 Kenyan shillings (approximately US $5) to reimburse them for their time and travel costs. The study was approved by the Monash University Human Research Ethics Committee (Australia) and the University of Nairobi and Kenyatta Hospital Ethics Committee (Kenya).
Following data analysis, we refined the intervention further by making recommended wording changes, emphasizing certain content, finalizing the structure (order, timing, and frequency of messages), and resolving technical implementation issues.
We held 6 workshops, each with 7 FSWs, in November 2015 to test the draft messages and refine the intervention. Workshops A and E were held solely with women who had experienced unintended pregnancy to allow open discussion of this issue. Most participants were in their mid-20s (median age 24 years, IQR 20-30) with some secondary education (secondary: 20/42, 48%; primary 15/42, 36%; tertiary: 7/42, 17%) and at least 1 child (34/42, 81%). They worked from a range of hotspots, with half working from bars or nightclubs. Just over half of participants owned a smartphone (the remainder had feature or basic mobile phones), and almost all used SMS at least daily. It was common for participants to share text messages (35/42, 83%), mostly with friends, and some also with family, boyfriends, and clients.
Participants felt that the topics covered were high priorities for FSWs and would be useful to their community. They confirmed that unintended pregnancy was an important issue that caused fear and stress, and relayed personal experiences of getting pregnant unintentionally. They particularly liked messages that gave general pregnancy prevention advice and information about IUDs.
Many sex workers fear getting pregnant [more] than HIV.
Message 2 is important…as female sex workers we must use family planning because we have many clients and we need to protect ourselves from becoming pregnant.
There was a strong positive response to messages on rights, violence, and alcohol use, particularly when violence hotlines were provided, and practical tips were given to reduce alcohol-related harms:
Many sex workers do not know their rights so by sharing with them [these] messages they will be informed.
Messages were considered highly relevant and spoke to participants’ real experiences, particularly the role model stories, with which participants strongly identified.
This information talks about what sex workers go through.
Many women volunteered personal stories that echoed message content. Common scenarios were pregnancy scares, difficulty negotiating condom use, experiences of violence, and contraceptive side effects. Role model stories in which the character gets drunk and then needs to use emergency contraception, and in which a woman overcomes contraceptive myths to use an IUD prompted the most discussion and personal anecdotes.
It is realistic. I had the experience when the condom busted and I was unable to access e-pills on time, therefore I conceived a baby and I had no option of aborting, therefore I carried pregnancy to term.
This thing happens to sex workers and it has happened to me, too.
Most women found the messages interesting and appealing, and several commented that the messages stimulated an interest in them to find out more. The majority in all groups agreed that they felt inspired by the role model stories.
It is inspirational especially when Sandra [character in a story] visits a health center for screening and also consults friends on STI prevention.
I am inspired. It shows us different family planning methods for example depo, IUD.
Positive tone also contributed to the appeal. When specifically asked about tone, the most common responses were that the messages were friendly (mentioned 21 times), educational (16), and polite (9). Six women also commented spontaneously that the messages were caring:
They are friendly because they let you know that there is someone who cares for you.
It is friendly. The message is like peers talking to me. It is not official.
Participants were asked if FSWs would trust the information provided. Most agreed they would, because the messages were caring and relevant to sex workers, and their community had been involved in developing them.
They will trust [the information] because somebody is caring for them.
This information is good and they will accept it and also [because] we have been involved.
Behavior change strategies adopted from social cognitive theory that were used to develop messages resonated with women. Strategies that were most strongly echoed in their responses were the provision of knowledge, change in outcome expectations, self-efficacy and skill development, and empowerment.
A large number of participants reflected that the messages taught them new and useful information. This was the response to both the program overall and specific topics, particularly messages on contraceptive options and side effects, IUDs, condoms, HIV, and alcohol. Participants from workshop A, who were less educated than other groups, were particularly keen to learn more.
I would like to learn more so I would enroll [in the program].
Friends would want to know more…Yes I will be taught then share the information, especially among sex workers on unwanted pregnancies.
Specific knowledge gaps were identified as negatively affecting individual participants and their community. Knowledge gaps in HIV transmission were mentioned 4 times, condom usage techniques 3 times, side effects of family planning twice, appropriateness of using IUD with multiple partners twice, menstrual cycles twice, and alcohol and rights once each.
Women frequently mentioned how messages challenged prevalent myths about contraception, particularly about side effects and appropriate use of IUDs:
I did not know that one can use a coil [IUD] and still have many partners.
I can relate to this episode because I knew with sperms my sitting allowance [buttocks] would increase and my side mirror [hips] would expand, but that was a myth. I have learnt.
However, some described incorrect ideas that they or their peers still held about contraception:
The coil is not good for sex workers because of the nature of work. We have different men of different [penis] sizes.
Only 2 participants stated that they did not learn anything new, indicating that the level of information was generally well targeted to participants’ background knowledge.
Outcome expectations raised by workshop participants and corresponding quotes.
Outcome expectations | Example quotes |
An outcome of using family planning is not getting pregnant and hence avoiding related stress |
“If I am with a client and I am on family planning, I will not fear issues of pregnancy.” (Age 24, Changamwe, workshop B) “When she [character in a role model story] uses coil, she is free and does not have fear of getting pregnant.” (Age 23, Kisauni, workshop D) |
Some contraceptive methods cause negative outcomes in the form of side effects but these are less severe than many perceive and can be addressed |
“These contraceptives have different effects: they lie to the body that you are pregnant [due to amenorrhea], but if you know the effects there is need not to worry.” (Age 20, Kisauni, workshop D) “It has inspired me, because I can use a coil and when I want a baby I can return to fertility and conceive.” (Age 19, Kisauni, workshop E) |
Getting drunk results in increased risk and bad business |
“If I get drunk when I go to the hotspot I will not be able to negotiate well with the client and I might be violated. I will not be able to get what I wanted.” (Age 19, Changamwe, workshop F) “When I am sober I will take care of myself from drama and keep myself safe, as sometimes men take advantage if one is drunk; he may refuse to pay you, steal your money and phone, or even not use a condom.” (Age 36, Kisauni, workshop C) |
If one accesses a service, they can expect to be provided with good quality care |
“When I go the clinic I can get help for an implant or STI treatment.” (Age 20, Changamwe, workshop A) “I have learnt that a health worker can listen to a sex worker and give advice.” (Age 24, Changamwe, workshop D) |
Role model stories appeared particularly well suited to supporting changes in outcome expectations and triggered responses in which women reflected on the behaviors of the characters, and the outcomes of their own behaviors and those of peers:
Yes; Lynette [character in story] was drunk and did not have a family planning method, if she had coil the situation could have been avoided.
My friend had a fear of using a coil, but when she went to hospital she was given advice and more information and she ended up using it, and it is not disturbing her.
Participants’ comments indicated a belief that they or their peers are capable of adopting certain behaviors, demonstrating self-efficacy for healthy behavior. They also reflected that some of the messages improved their skills and confidence to adopt new behaviors. Messages that provided specific skills and techniques to lower drinking risk, and specific tips on condom use, were particularly well-received:
I can talk to the waiter and exchange beer with water.
Violence and rights messages prompted statements reflecting increased self-efficacy for recognizing rights, seeking help, and negotiating with clients:
I know now I am the boss and I can negotiate for payment with clients.
These messages will teach them their rights, and how they can negotiate and report cases if violated.
Messages on what to expect from service providers also prompted a response that suggested women felt capable of accessing services:
It is true—the job of the health care is to give services, and I can find a clinic where I am comfortable.
Participants liked messages that suggested specific actions or plans, and they were triggered to think about what they should do in different situations and how they could make the best use of the messages:
I will put a reminder on the message that I have received, for example when I am at the hotspot.
If one contraceptive is not good for you, change to another one.
When I go out I should have a friend or talk to the receptionist at the hotspot to check on my security, and not go with the money in the room.
Empowerment refers to a process in which individuals and communities gain control over their lives and the issues that most affect them, and includes the development of self-confidence and self-reliance [
It is about me, myself and I. I deserve to be happy and know my rights. Yes I like this message [about rights of sex workers].
We should visit people who can listen to our voice or our complaints, and health workers should not stigmatize us when we go for services.
There was a sense that the messages prompted improved morale and inspired them to take action. A number of women specifically mentioned the importance of being in control, particularly in response to role model stories. Stories about the use of LARCs also prompted a sense of being free from the fear of getting pregnant:
They give me morale to use condoms.
Dual methods remove fear. I have total control when I have the implant and use condoms.
Participants were overwhelmingly in favor of sharing the messages with other sex workers and friends, and to a lesser extent, with family members, boyfriends, clients, and health workers. Almost all said they would share messages when asked directly, and many said that they would do so without prompting, consistent with the existing practice of frequent sharing. The desire to share influenced their preferences for message delivery. Participants in workshop E preferred SMS because it is an easy format to share. Those in workshops A and B wanted to receive the messages before starting work, to allow time to discuss them with others at the hotspot. Many indicated that it was important for both sex workers and the broader community to have access to this information, and that, as holders of the messages, they would be empowered to provide it. There was a real enthusiasm expressed for teaching others:
My friends do not have this information, therefore I will reach out to them and share with them.
I will share with 15 and 16 year age groups, because they do not know about family planning and they are already engaging in sex.
I will share with my clients so that they can reach their spouses.
By teaching others these messages they will help me to remember.
One workshop participant thought that she could contact WHISPER to receive emergency assistance (“If am assaulted I can send message or call to get help”; age 40, Kisauni, workshop C). As WHISPER is an automated system, such requests cannot be followed up, and it was concerning that the women may have thought they could depend on the program in this way. This was addressed in subsequent changes to the program (described below).
Breach of privacy was also raised as a potential risk. Participants in 3 workshops discussed the risk that someone else would see the messages and would assume that they were sex workers and/or HIV positive. Some were afraid that this could cause conflict with their boyfriends.
It will bring conflict between me and my boyfriend who might be nosy especially on information on STIs.
It depends on the person and the relationship you have with them. For example, if a parent sees information about a condom he or she will react, but you can explain. If a client or a boyfriend sees information on HIV he will panic.
However, not all agreed, and there was a discussion about how the messages might be good for other people, including their boyfriends, illustrated in this interaction:
Even the boyfriends want to plan a family, so they cannot deter us from using this service.
These messages will be good for both parties—man and woman.
Others felt that the messages would be socially acceptable. For example, workshop A participants thought friends and health care workers would be impressed that they were
My boyfriend, family or friend will say I am informed.
Another risk is that the program would not overcome barriers to healthy behaviors in sex work. Responses illustrated how some barriers cannot be overcome by an individually targeted intervention alone. For example, a role model story about a client offering to pay extra for no condom prompted discussion in workshop F about the need to balance conflicting outcome expectations of different courses of action. This reflected sex workers’ need to continually assess risk, and the fact that money and immediate safety are often higher priorities than pregnancy and STI prevention.
The client of Joslyn [character in the story] in this case was polite, because he said he will call next week, but most clients will become abusive if you refuse to not use condoms.
The issue is money. That is why female sex workers risk going without a condom—so that she might get a client.
I had a friend who had the same issue. She judged the guy with looks because the guy had money. She did not negotiate for condom before. The money was huge. The lady refused because this guy insisted no condom.
Interview participants were sent messages with a link to the on-demand system. In all, 7 of 12 participants found it
Many women liked having the option to retrieve more information and the interactive aspect of the system. They talked about the ease of getting detailed information on their phones rather than having to seek it out from health professionals, and the ability to refer back to such messages later. A number of women did not feel the initial message on a topic contained new information, but obtaining more detail allowed them to gain a greater understanding.
It has motivated me since I can get instant replies and can be helped instantly.
It is like revision [on] family planning⸺when I am reading I am being enlightened more and remembering, it is easy.
Messages about health services were considered very useful to participants and their peers as they provided information that was not easy to obtain and saved the time and resources needed to find appropriate services. The emergency message (developed in response to workshop feedback—described below) was particularly popular and seen as important.
When I need help, or having an emergency, they have provided a number which I can call for free in case of violence and has given me a whisper menu too. In short they have not left me hanging from the situation I may be experiencing.
There were some technical issues during interviews, including delayed receipt of messages and (erroneous) warnings received from network providers, which deterred some women from continuing. Despite these challenges, most interview participants were very engaged in the process of retrieving pull messages, and those who had initial difficulty still enjoyed the process. When asked directly, all agreed that they would like to continue using the system.
Workshop participants had generally consistent preferences regarding how the intervention should be delivered. The majority were in favor of text rather than voice modality and preferred push messages to retrieving content via a pull system. Most women reported that their texting practices involved a mixture of English and Swahili, and they favored English for health messages, with some keywords or phrases in Swahili. Participants wanted to receive messages several times a week for at least 1 year and preferred to receive them in the late morning on set days to align with their typical work schedules.
A number of changes were made to the intervention content and form based on findings. To minimize the risk of women expecting emergency assistance from WHISPER, a message was included on what to do in an emergency, specifically around violence. An
The other key concern identified was the risk of sex work status being discovered by clients or boyfriends viewing the messages. In response to this, we minimized overt references to sex work and clients wherever possible.
Suggestions were adopted from participants regarding the use of specific words and terms, in both Swahili and English. Terms of endearment like
A number of strategies were adopted to address the technical challenges encountered using the on-demand system. These included testing the system with each participant during their enrolment and incorporating introductory messages that explained how to use the on-demand menu.
The intervention components and delivery schedule were finalized based on workshop and interview results. Over a 12-month intervention period, participants received SMS 2 to 3 times per week, alternating push messages with role model stories every month. A total of 82 push messages were developed for the intervention (see examples in
We provide the first description of the development of a digital health intervention for FSWs that uses a comprehensive SRHR framework. The participatory approach enabled FSWs to influence the range and content of topics included in the intervention [
Furthermore, health behavior change interventions are more effective when they are based on social and behavioral science theory, and the use of multiple theories may increase intervention effectiveness [
The messages increased participants’ feelings of empowerment [
Participants reinforced the importance of the selected SRHR topics and confirmed that unintended pregnancy is a major concern for sex workers. The team was careful to ensure that scenarios were not overly optimistic and appropriately represented known barriers. Content addressing family planning myths was stated in different ways and different formats (push and pull messages and role model stories) to maximize the potential that participants would engage with and learn from the WHISPER content so that myths would no longer represent barriers to participants.
In addition to family planning, alcohol use and gender-based violence were viewed as important. Strategies for reducing drinking provided in the text messages were adapted from effective harm reduction interventions [
The intervention was highly acceptable to both workshop and interview participants. Women were interested and engaged in both the content and the format of delivery, with role model stories eliciting particularly enthusiastic discussion, and SMS confirmed as the preferred technology. Workshop and interview participants demonstrated familiarity and comfort using SMS, and desire to learn more, suggesting that it is feasible for SRHR messages to be sent regularly over a year to this population. Testing during interviews confirmed the feasibility of the on-demand system. Most participants could retrieve pull messages with relative ease; however, women who are less educated or have less experience with mobile phones may experience difficulty using this system.
There were some technical issues, including a network warning that could not be deactivated. Similar problems have been identified by other implementers of mHealth programs [
We have demonstrated that WHISPER is feasible to implement and acceptable to the target audience; however, this may not translate to sufficient participant engagement to produce better health outcomes. Engagement with a digital health program incorporates not only the subjective and cognitive responses that are triggered (which are explored in this paper) but also the extent of use [
Our research revealed several risks to participation in a digital health SRHR intervention. First, participants believed that they could receive emergency assistance from WHISPER. It is possible that the friendly and personal tone—while effective in generating intervention engagement [
Second, disclosure of sensitive messages could result in increased conflict with boyfriends or clients, although it also has the potential to improve communication with partners. Disclosure risk has been explored during the development of mHealth interventions for HIV [
This study had some important limitations. We used purposive sampling and cannot ensure that workshop participants were representative of the larger FSW population. In addition, our approach to data collection and analysis was highly directive, and some messages were not tested because they were from preexisting mHealth interventions [
This research provides a clear illustration of the many issues that preoccupy FSWs in their day-to-day lives—beyond the traditional biomedical focus on HIV risk and transmission. Our results support the need for health promotion interventions that utilize a participatory approach to intervention development and are based on social and behavioral science to increase their relevance and effectiveness. The resulting WHISPER digital health intervention reflects the complex reality of FSWs’ daily lives and provides a feasible, engaging, and confidential approach for addressing their SRHR concerns and needs.
female sex worker
intrauterine device
long-acting reversible contraceptive
National Health and Medical Research Council Australia
randomized controlled trial
sexual and reproductive health and rights
sexually transmitted infection
Women’s Health Intervention using SMS for Preventing Pregnancy
This work was supported by the National Health and Medical Research Council Australia (NHMRC) under Project Grant GNT 1087006, NHMRC Career Development Fellowships for SL and MS, and an NHMRC Postgraduate Scholarship for FA. The authors would like to acknowledge the FSW peer educators and research assistants who contributed to this work. We also gratefully acknowledge the contribution to this work of funding from the Victorian Operational Infrastructure Support Program received by the Burnet Institute.
None declared.