Abstract
Objectives. To evaluate whether text-messaging programs can improve reproductive health among adolescent girls in low- and middle-income countries.
Methods. We conducted a cluster–randomized controlled trial among 756 female students aged 14 to 24 years in Accra, Ghana, in 2014. We randomized 38 schools to unidirectional intervention (n = 12), interactive intervention (n = 12), and control (n = 14). The unidirectional intervention sent participants text messages with reproductive health information. The interactive intervention engaged adolescents in text-messaging reproductive health quizzes. The primary study outcome was reproductive health knowledge at 3 and 15 months. Additional outcomes included self-reported pregnancy and sexual behavior. Analysis was by intent-to-treat.
Results. From baseline to 3 months, the unidirectional intervention increased knowledge by 11 percentage points (95% confidence interval [CI] = 7, 15) and the interactive intervention by 24 percentage points (95% CI = 19, 28), from a control baseline of 26%. Although we found no changes in reproductive health outcomes overall, both unidirectional (odds ratio [OR] = 0.14; 95% CI = 0.03, 0.71) and interactive interventions (OR = 0.15; 95% CI = 0.03, 0.86) lowered odds of self-reported pregnancy for sexually active participants.
Conclusions. Text-messaging programs can lead to large improvements in reproductive health knowledge and have the potential to lower pregnancy risk for sexually active adolescent girls.
More than 13 million adolescent girls give birth each year, and greater than 95% of these births occur in low- and middle-income countries (LMICs).1 Adolescent pregnancies are associated with an increased risk of unsafe abortion,2 low birth weight and preterm delivery,3 birth complications,4 child stunting,5 and early school exit and social stigmatization for adolescent mothers.6 Despite the large number of risk factors associated with adolescent pregnancies, reproductive health knowledge and the adoption of modern contraception remain low in many developing countries.7,8 In many countries in sub-Saharan Africa, more than 50% of unmarried, sexually active 15- to 19-year-old adolescents have an unmet need for modern contraception.2,9
Over the past 10 years, mobile phone access has skyrocketed in LMICs, from 22 subscriptions per 100 people in 2005 to 90 in 2014.10 Text-messaging programs offer a promising new platform to improve sexual and reproductive health, in particular among adolescents, by providing information in a private and confidential way. The past decade has seen a rapid rise in text-messaging programs that aim to improve health11–13; however, systematic reviews have consistently found a dearth of high-quality peer-reviewed studies examining outcomes of these programs in LMICs.14–17 Despite a large number of recent projects leveraging mobile technology among adolescent populations in LMICs, none of these employs a randomized trial design to provide evidence of effectiveness.18–23
To examine the potential of text-messaging sexual-education programs to improve adolescent reproductive health, we conducted a randomized controlled trial in Ghana, investigating the effectiveness of both 1-way and 2-way text-messaging programs on knowledge and sexual behavior. Ghana provides an ideal setting for this study both because of the high rates of cell phone access (115 mobile phone subscriptions per 100 people in 2014)10 and because of the large gaps in adolescents’ reproductive health knowledge.
METHODS
We conducted this cluster–randomized trial in Accra, Ghana. According to the most recent estimates, half of Ghanaian women have sexual intercourse before the age of 18 years, but less than a third of sexually active unmarried girls aged 15 to 19 years use any form of modern contraception.24 The prevalence of adolescent pregnancy remains high: 42% of sexually experienced 15- to 19-year-old girls report previous pregnancies, with 3 in 5 births classified as unintended.25 Reproductive health knowledge is low: 56% of Ghanaian female adolescents consider washing after sexual intercourse an option to prevent pregnancy and 62% are not aware that a girl can get pregnant if she has sex while standing up.26
The sampling frame for the study was provided by the 2012–2013 Ghana Education Service Register of Secondary Schools in Greater Accra. The primary sampling unit for the study was secondary schools. We restricted sampling to day schools (we excluded boarding schools). Within schools, we restricted sampling to girls aged 14 to 24 years. Participants gave written consent, with those younger than 18 years obtaining parental consent, and were informed that they could exit the study at any time.
We randomized 38 schools to unidirectional intervention (n = 12), interactive intervention (n = 12), and the control group (n = 14). Randomization was based on a computer-generated random number draw by the principal investigator. We stratified randomization by school category (a measure of quality designated by the Ghana Education Service) and by whether the school had a home economics class. Study participants and data collection staff could not be masked because the intervention required overt participation. We used a cluster design to encourage communication about the intervention among participants in the same school with the objective of reducing social stigma and increasing social support for discussing sexual health issues.
Recruitment
We recruited participants between January 15 and February 28, 2014. We visited schools to secure agreement of the headmaster or headmistress and to select a specific class within the school. All chosen classes were in their second year of senior secondary school (similar to grade 11 in the United States). We chose classes with the objective of maximizing the number of girls with the following process. If a home economics class was offered at the school, we chose the home economics class for the study because most students studying home economics in Ghana are female; if a home economics class was not offered, the investigators worked with the school head to choose a class that had a large number of female students.
We invited female students in the chosen class of each school to participate in the study. Girls who refused consent and all boys were asked to step outside for the duration of the study visit. Participants in all groups were told they would receive “health messages” on their phones, including such topics as reproductive health or malaria. Participants used their own mobile phones or could use a family member’s phone. Participants without phones were eligible to be enrolled in the trial; however, phones were not provided. After enrollment, participants in the interactive intervention group received a brief training on how to respond to the quiz questions.
Interventions
We designed the study to evaluate the effectiveness of 2 interventions. As part of the unidirectional intervention, participants were sent 1 reproductive health message via text message once a week. These messages focused on pregnancy prevention and contained information on topics of reproductive anatomy, pregnancy, sexually transmitted infections (STIs), and contraception including male condoms, female condoms, birth control pills, and emergency contraception (see Table A, available as a supplement to the online version of this article at http://www.ajph.org, for complete content). Message content was generated after extensive focus groups with young adults before the launch of the study, with the goal of understanding the most popular sexual health topics of interest, as well as guidance from the Ghana Health Service Health Promotion Unit, who edited wording and approved appropriateness of the content for this age group.
As part of the interactive intervention, participants were not sent any information initially, but were instead sent 1 multiple-choice quiz question via text message each week to which they were invited to respond free of charge. Upon responding, participants immediately received a confirmatory text message informing them whether they answered correctly along with the correct answer and additional information, which corresponded to the information provided in the unidirectional intervention. During the course of the week, participants were sent up to 2 reminder messages encouraging them to respond if they had not yet responded. Participants who never responded were sent a text message with the correct answer and the additional information at the end of the week. For every 2 correct responses, participants were sent an airtime credit reward of 1 GHS (US $0.38). Airtime credit rewards were sent at the end of the week, along with a message informing participants of how many questions they had correctly answered and encouraging them to continue participating.
The control group participants were sent placebo messages once a week with information about malaria. All programs ran for 12 weeks.
As part of the intervention, the unidirectional and interactive groups also received 4 extra tips about the effectiveness of condoms, the benefits of talking with their boyfriend about reproductive health, and the existence of a free public hotline number that they could call for reproductive health information (sent twice). This was done as a means of increasing access and communication of reproductive health information. After the 3-month follow-up, participants in both intervention and control arms were offered a 30- to 45-minute lecture about reproductive health by a nurse recruited by the Alliance for Reproductive Health Rights, a Ghanaian nongovernmental organization.
All messages were in English, the language of secondary school instruction in Ghana, and automatically sent to participants through a computerized system. If a message was not delivered, it was resent. Study staff maintained a record of all incoming and outgoing text messages with participants.
Procedures and Outcomes
Participants completed a written baseline questionnaire, a follow-up questionnaire 3 months later, and a second follow-up questionnaire 15 months after baseline. Study staff proctored the questionnaires under test-taking conditions. Participants provided demographic information at baseline. Reproductive health knowledge was recorded at baseline and at both the 3-month and 15-month follow-ups. Information on sexual behavior and pregnancies was collected only at the 15-month follow-up. Participants completed self-administered questionnaires at baseline and the 3-month follow-up on paper; at the 15-month follow-up, they self-administered the questionnaire on tablet computers to maximize privacy for individual responses about sexual behavior.27
The primary outcome was reproductive health knowledge. Participants completed a quiz with 24 true-or-false questions at both the 3-month and 15-month follow-ups (see Table B, available as a supplement to the online version of this article at http://www.ajph.org, for details). At 15 months, we additionally evaluated the impact of the interventions on self-reported pregnancy, sexual activity, and contraceptive use (see Table C, available as a supplement to the online version of this article at http://www.ajph.org, for definitions of all outcome variables).
Statistical Analysis
The study was powered to detect an improvement of 15 percentage points in the knowledge score with power equal to 0.9 and an α of 0.05 in pairwise comparisons between the control arm and each of the 2 intervention arms. This calculation was based on an average of 30 participants in 12 schools in each arm, and an intraclass correlation coefficient of 0.05 (a design effect of 2.5).
We used linear regression models (ordinary least squares) to estimate intent-to-treat effects on knowledge and multilevel logistic regression models for self-reported pregnancy and sexual behavior outcomes. For age at sexual debut, we used a linear regression model. We estimated 2 multivariable regression models for each outcome—the first adjusting only for stratification variables, and the second additionally adjusting for baseline individual- and school-level characteristics, including age, ethnicity, religion, mother’s education, father’s education, school size, and baseline knowledge.
For linear regression models, standard errors were clustered at the school level to correct for within-school correlation of outcomes. Logistic regression models included school random effects. We used R (version 3.1.1; R Foundation, Vienna, Austria) for all analyses. The study design was registered on ClinicalTrials.gov (NCT02031575).
RESULTS
A total of 38 schools were eligible for randomization (Figure 1). After randomization, we found 3 schools to be ineligible (they were boarding schools) and 1 refused on the basis of time constraints. The final sample included 34 schools with 12 schools assigned to the unidirectional intervention, 10 schools assigned to the interactive intervention, and 12 schools assigned to control group. A total of 756 participants enrolled in the study, of which 716 (95%) were successfully followed up at 3 months and 721 (95%) were successfully followed up at 15 months. Of those participants followed up at 3 months, 99% had provided a phone number at baseline and 83% claimed to have received at least 1 text message. Participants who used a family member’s phone were less likely to report receiving messages than those who owned a phone (71% compared with 86%, respectively). In the interactive group, weekly response rates to the quiz questions remained relatively stable, ranging from 64% to 70% over the 12-week intervention duration. Table 1 shows baseline demographic characteristics and knowledge scores, which were evenly distributed among the groups.
FIGURE 1—
Profile of Cluster–Randomized Controlled Trial of Text-Messaging Programs and Reproductive Health Among Adolescent Girls in Ghana, 2014
TABLE 1—
Baseline Characteristics of the Intent-to-Treat Population in a Cluster–Randomized Controlled Trial on the Impact of Text-Messaging Programs on Reproductive Health Among Adolescent Girls in Ghana: 2014
| Characteristic | Control | Unidirectional | Interactive |
| No. of clusters | 12 | 12 | 10 |
| No. of total participants | 293 | 258 | 205 |
| Median participants per cluster (range) | 22.5 (7–48) | 20.5 (3–46) | 19.5 (4–39) |
| Participated at 3-mo follow-up, no. (%) | 286 (98) | 238 (92) | 192 (94) |
| Participated at 15-mo follow-up, no. (%) | 277 (95) | 247 (96) | 197 (96) |
| Mean age, y (SD) | 17.8 (1.2) | 17.6 (1.4) | 17.6 (1.5) |
| Religion,a no. (%) | |||
| Muslim | 52 (18) | 37 (14) | 24 (12) |
| Catholic | 21 (7) | 21 (8) | 18 (9) |
| Spiritual, Pentecostal, or Charismatic | 128 (44) | 120 (47) | 93 (45) |
| Protestant | 61 (21) | 61 (24) | 54 (26) |
| Other | 26 (9) | 14 (5) | 12 (6) |
| Mother’s education,b no. (%) | |||
| Don’t know | 72 (25) | 56 (22) | 47 (23) |
| < secondary | 47 (16) | 46 (18) | 22 (11) |
| ≥ secondary | 170 (58) | 154 (60) | 135 (66) |
| Father’s education,c no. (%) | |||
| Don’t know | 65 (22) | 42 (16) | 41 (20) |
| < secondary | 119 (41) | 109 (42) | 77 (38) |
| ≥ secondary | 105 (36) | 106 (41) | 86 (42) |
| Ethnicity,d no. (%) | |||
| Akan | 112 (38) | 113 (44) | 70 (34) |
| Ga | 86 (29) | 61 (24) | 68 (33) |
| Ewe | 42 (14) | 49 (19) | 39 (19) |
| Other | 41 (14) | 23 (9) | 25 (12) |
| Own phone,e no. (%) | |||
| Yes | 247 (84) | 219 (85) | 177 (86) |
| No, but have access | 38 (13) | 29 (11) | 24 (12) |
| No, no access | 2 (1) | 5 (2) | 3 (1) |
| Baseline knowledge score, mean (SD) | 0.26 (0.16) | 0.30 (0.17) | 0.31 (0.18) |
Data missing for 5 control, 5 unidirectional, and 4 interactive participants.
Data missing for 4 control, 2 unidirectional, and 1 interactive participants.
Data missing for 4 control, 1 unidirectional, and 1 interactive participants.
Data missing for 12 control, 12 unidirectional, and 3 interactive participants.
Data missing (although phone number was provided by all) for 6 control, 5 unidirectional, and 1 interactive participants.
Figure 2 shows the adjusted means of the knowledge score for the interactive, unidirectional, and control groups at 0 (baseline), 3, and 15 months (estimates are reported in Table D and Figure A, available as supplements to the online version of this article at http://www.ajph.org). From baseline to the 3-month follow-up, average knowledge scores increased from 26% to 32% in the control, 30% to 45% in the unidirectional, and 31% to 60% in the interactive groups. After we adjusted for covariates, average knowledge in the unidirectional and interactive groups was 11 percentage points (95% confidence interval [CI] = 7, 15) and 24 percentage points (95% CI = 19, 28) greater than in the control group, respectively. The interactive intervention was significantly more effective than the unidirectional intervention, with an additional knowledge score increase of 13 percentage points (95% CI = 8, 18). At 15 months, these gains were largely sustained, although the control group caught up over time to the unidirectional group; average knowledge in the interactive group was 11 percentage points (95% CI = 8, 15) greater than in the control group, and the unidirectional intervention was no longer significantly different from the control group (3 percentage points higher; 95% CI = –1, 7). We conducted an additional analysis that included only participants who owned a phone; results are similar to those with the full sample (data not shown).
FIGURE 2—
Adjusted Mean and 95% Confidence Intervals of Knowledge Score at 0 (Baseline), 3 Months, and 15 Months for Interactive, Unidirectional, and Control Groups in Cluster–Randomized Controlled Trial on the Impact of Text-Messaging Programs on Reproductive Health Among Adolescent Girls in Ghana, 2014
Note. Estimates are predicted scores obtained from a linear regression of knowledge score on intervention group and adjusted for presence of home economics class, school category, age, religion, ethnicity, mother’s education, father’s education, school size, and baseline knowledge.
Table 2 shows the results for self-reported pregnancy and sexual behavior from both unadjusted and adjusted models. Although the direction of the effects found in both models stays the same, the point estimates vary and standard errors in the adjusted models are generally narrower as a result of the additional control variables. There was no significant impact of either intervention on ever having sexual intercourse, on having sexual intercourse in the past year, or on pregnancy in the past year for the full sample of participants (Table 2).
TABLE 2—
Estimated Intervention Effects for Self-Reported Pregnancy and Sexual Behavior Among Adolescent Girls in Ghana in a Cluster–Randomized Controlled Trial on the Impact of Text-Messaging Programs on Reproductive Health: 2014
| Unidirectional—Control |
Interactive—Control |
||||||
| Variable | Control, No. (%) | Unidirectional, No. (%) | Interactive, No. (%) | Crude OR (95% CI) | AOR (95% CI) | Crude OR (95% CI) | AOR (95% CI) |
| Full sample | |||||||
| Ever had sexual intercourse | 88/273 (32) | 83/239 (35) | 64/196 (33) | 1.04 (0.71, 1.52) | 1.06 (0.71, 1.58) | 1.29 (0.85, 1.95) | 1.24 (0.80, 1.93) |
| Sexual intercourse in past year | 58/273 (21) | 64/243 (26) | 51/196 (26) | 1.21 (0.80, 1.84) | 1.22 (0.79, 1.87) | 1.54 (0.97, 2.44) | 1.55 (0.96, 2.50) |
| Pregnant in past year | 10/276 (4) | 5/243 (2) | 6/193 (3) | 0.51 (0.17, 1.54) | 0.39 (0.12, 1.29) | 0.85 (0.27, 2.69) | 0.59 (0.17, 2.00) |
| Sexually active sample | |||||||
| Pregnant in past year | 9/58 (16) | 5/63 (8) | 4/51 (8) | 0.40 (0.12, 1.38) | 0.14 (0.03, 0.71) | 0.42 (0.10, 1.70) | 0.15 (0.03, 0.86) |
| Used any contraception past year | 26/56 (46) | 35/60 (58) | 25/46 (54) | 1.77 (0.83, 3.79) | 1.52 (0.68, 3.43) | 1.27 (0.56, 2.90) | 1.18 (0.48, 2.90) |
| Used contraception at last sexual intercourse | 27/54 (50) | 36/59 (61) | 27/50 (54) | 1.61 (0.75, 3.49) | 1.40 (0.61, 3.22) | 1.28 (0.57, 2.91) | 1.17 (0.48, 2.85) |
| Used condom at sexual debut | 30/54 (56) | 34/62 (55) | 27/49 (55) | 0.99 (0.46, 2.11) | 0.83 (0.36, 1.89) | 1.14 (0.50, 2.63) | 0.97 (0.39, 2.40) |
| Had sexual intercourse without condom past year | 38/57 (67) | 48/62 (77) | 42/49 (86) | 1.50 (0.65, 3.48) | 1.85 (0.73, 4.70) | 2.80 (1.02, 7.70) | 3.47 (1.12, 10.74) |
| Used condom in past year | 15/58 (26) | 17/64 (27) | 16/51 (31) | 1.17 (0.51, 2.69) | 1.14 (0.47, 2.79) | 1.29 (0.53, 3.13) | 1.25 (0.48, 3.23) |
| Used birth control pill in past year | 1/58 (2) | 5/64 (8) | 5/51 (10) | 4.91 (0.55, 43.40) | 5.04 (0.50, 50.49) | 6.88 (0.73, 64.72) | 13.23 (1.08, 161.80) |
| Used emergency contraception in past year | 10/58 (17) | 11/64 (17) | 4/51 (8) | 1.07 (0.36, 3.13) | 0.81 (0.28, 2.34) | 0.31 (0.08, 1.25) | 0.22 (0.05, 0.88) |
Note. AOR = adjusted odds ratio; CI = confidence interval; OR = odds ratio. Odds ratios from multilevel logistic regression model with school random effects. Crude model adjusted for stratification variables—that is, presence of home economics class and school category. Adjusted model additionally adjusted for age, religion, ethnicity, mother’s education, father’s education, school size, and baseline knowledge. One participant in the control group and 2 in the interactive group reported being pregnant in the past year but not having sexual intercourse in the past year. We did not recode them; however, analysis including those participants in the sexually active sample does not change the direction or the significance of the results.
Conditional on having sexual intercourse in the past year, the unidirectional and the interactive programs significantly lowered the odds of self-reported pregnancy by 86% in the adjusted models (odds ratio [OR] = 0.14; 95% CI = 0.03, 0.71) and 85% (OR = 0.15; 95% CI = 0.03, 0.86), respectively, compared with the control group (Table 2). The interactive intervention increased the odds of using the birth control pill in the past year (OR = 13.23; 95% CI = 1.08, 161.80) although small sample sizes resulted in large confidence intervals. The interactive intervention also decreased the odds of using emergency contraception (OR = 0.22; 95% CI = 0.05, 0.88). The interactive intervention appeared to increase risk of sex without a condom in the past year (OR = 3.47; 95% CI = 1.12, 10.74). There was no impact on age of sexual debut for those who have ever had sexual intercourse (Table E, available as a supplement to the online version of this article at http://www.ajph.org).
DISCUSSION
The results presented in this study suggest that text-messaging programs can be effective tools to improve reproductive health knowledge among adolescents. We observed large improvements in knowledge at 3 months that were sustained after 15 months for both 1-way and 2-way programs. However, the 2-way interactive program was significantly more effective at increasing knowledge than the 1-way program. For the sexual behavior outcomes, results were mixed. Among sexually active adolescents, we found both programs to be protective against self-reported pregnancies; however, we found no significant impact on pregnancy in the full sample. Larger impacts on reproductive health outcomes seem plausible once a majority of treated women become sexually active.
Somewhat surprisingly, we found that the interactive intervention was positively associated with having sex without a condom among sexually active adolescents in the interactive group. The main focus of the intervention content was on pregnancy prevention rather than on STIs, which appears to have resulted in a move away from condoms as a primary method of contraception with a shift toward birth control pills. Other studies have found that fear of pregnancy, not of STIs, motivates Ghanaian adolescents to use contraceptives.25 However, in settings where HIV and other STI rates are high, these messages may not be appropriate. This study highlights the importance of carefully adjusting content and framing of mobile phone programs to local public health needs.
Interestingly, control group participants increased their knowledge over time. We speculate that this may have been attributable to a combination of learning about reproductive health from other sources such as the media, from the nurse’s lecture at the 3-month follow-up, or because of repeated questionnaires about these issues at baseline and 3 months.
Limitations
This study had several limitations. First, for reproductive health outcomes, the study exclusively relied on self-reported measures. It is possible that respondents in intervention groups may have felt more pressure to misreport their sexual behavior. Because they received messages that encouraged use of contraception to prevent unintended pregnancy, they may have consequently underreported pregnancy. The direction of this bias is not obvious, however, as the exposure to the programs may have increased familiarity and openness to sexual health questions, so that program participants may have been more likely to report undesired outcomes than the control participants (such as sex without a condom). To mitigate misreporting concerns, all questions at the 15-month follow-ups were asked via self-administered tablet computers, which have been shown to increase honesty in adolescent responses of sexual behavior.27 Nevertheless, self-reported sexual behavioral data among adolescents has been found in other contexts to suffer from recall error, misunderstanding, and social desirability bias; biological markers of pregnancy and sexual health are needed to better understand the health impact of the programs.28 In addition, the 15-month questionnaire elicited respondents’ primary use of contraception; if some women used multiple methods, we could have underestimated the impact of the intervention on use of condoms, birth control, and emergency contraception.
Second, the interactive program was a multicomponent intervention that included interactive quizzes, financial incentives, and reminder messages; we are not able to discern which components made the biggest impact on knowledge. Third, we included only adolescent girls in secondary school in Accra; program impact may be different among high-risk girls, boys, and adolescents in rural areas or other countries. Evidence from a review of 83 sexual-education programs across the world evaluating the impact of sexual education on knowledge, attitudes, and behaviors found that programs that had positive effects were equally effective in both rural and urban areas, among girls and boys, and among low- and middle-income youths, and that replication of effective studies in other settings yielded consistent results.29 Finally, neither the participants nor the study staff could be masked to assignment. However, staff were trained to provide the same description of the messages to all groups to prevent differential uptake. Similarity of baseline characteristics across groups indicates that the participants were comparable.
An important consideration is that of selective attrition. We believe that this risk is minimal in our study; we followed up more than 94% of participants in all 3 arms and confirmed pregnancy status for 28 of the 35 lost participants by asking classmates and school administrations about their status.
Intention-to-treat estimates may be conservative estimates of the true causal effects of the intervention as 17% of girls did not receive any messages because of technical challenges as well as decreased phone access among girls who did not own their own phone. However, these are common problems in text-messaging programs and future research or program scale-up should keep these challenges in mind.17
Public Health Implications
School-based comprehensive sexual education in a study context has been found to be largely effective at increasing knowledge; behavioral impacts have been observed for some programs, though less consistently.29–32 However, poor implementation of school-based programs at scale, including problems of curricula lacking basic information on condoms and contraception, poor teaching, and short program durations, have often resulted in a lack of fidelity to the designed intervention, reducing program effectiveness.33 Our study supports the idea that text-messaging programs may be effective ways to fill this gap, by providing accurate and complete information via a medium with which adolescents are comfortable. Moreover, text-messaging programs can be tailored to the audience both in terms of cultural and individual characteristics,34 and they can inexpensively reach a large and diverse population—the marginal costs of the interactive and unidirectional programs per participant were US $1.91 and US $0.30, respectively.
The past decade’s rapid rise in mobile phone access provides an opportunity to harness this technology to improve health, particularly in LMICs.10 Young people are the most likely age group to use their phone to send text messages in LMICs,35 yet very few mobile health interventions have been developed for and evaluated on adolescents in LMICs.15,16,34 The results of this trial suggest that mobile platforms are indeed a feasible platform for improving adolescent health knowledge and, ultimately, health outcomes. More research is needed to examine the impact of adolescent text-messaging programs on objective measures of reproductive health and over the long term in LMICs.
ACKNOWLEDGMENTS
This research was funded by the Weiss Family Fund for Research in Development Economics, the Harvard Lab for Economic Applications and Policy, and the Harvard Institute for Quantitative Social Science.
We thank Mary Beth Landrum and Mark McGovern for their feedback and support. We are grateful to the participants and the administrations of the schools that participated in the trial. We thank Comfort Bonney Arku, Grace Gletsu, Maham Farhat, Christine Papai, Richard Adanu, Philip Amara, and the Innovations for Poverty Action staff who contributed to this study for their hard work and support. We thank Grace Kafui Annan and staff at the Ghana Health Service Health Promotion Unit for their guidance and support.
Note. Study sponsors had no role in study design, data collection, analysis, interpretation, writing of the article, or decision for publication.
HUMAN PARTICIPANT PROTECTION
Institutional review board approval was granted by the Committee on the Use of Human Subjects in Research at Harvard University (IRB13-1647) as well as the Ghana Health Service Ethical Review Committee (GHS-ERC:05/09/13).
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