Targeted Behavior Change Communication Using a Mobile Health Platform to Increase Uptake of Long-Lasting Insecticidal Nets Among Pregnant Women in Tanzania: Hati Salama "Secure Voucher" Study Cluster Randomized Controlled Trial.

Abstract

Background: Malaria remains a significant cause of maternal and neonate morbidity and mortality in sub-Saharan Africa. Long-lasting insecticidal nets (LLINs) represent an important component of malaria prevention and can decrease the adverse health outcomes associated with malaria infection during pregnancy. Voucher programs have been successfully implemented for a variety of initiatives across sub-Saharan Africa, including the distribution of subsidized LLINs in Tanzania. However, mobile messaging for behavior change communication (BCC), in combination with an e-voucher program, has not been explored for malaria prevention.

Objective: This study aimed to assess the efficacy of mobile messaging in increasing the redemption of e-vouchers for LLINs for pregnant women and adolescents in Tanzania.

Methods: This study was a blinded, 2-arm, cluster randomized controlled trial implemented in 100 antenatal health facilities in Tanzania (both urban and rural settings), with 50 clusters in both intervention and control groups. Clusters were antenatal clinics with e-voucher capabilities, with randomization stratified such that 25 urban and 25 rural clinics were randomized to each arm. Participants were pregnant females aged 13 years or older. Participants in both intervention and control groups were issued e-vouchers on their mobile phones that could be redeemed for LLINs at registered retailers within a 14-day redemption period. Participants in the intervention group received targeted BCC messages about the importance of malaria prevention and LLIN use during pregnancy, while participants in the control group did not receive BCC messages. Analyses were by intention to treat. The primary outcome was the redemption rate of e-vouchers for LLINs from retailers. Outcome measures pertain to clinic sites and individual participant-level data.

Results: The study enrolled 5449 participants; the analysis included 2708 participants in the intervention arm and 2740 participants in the control arm (49 clusters in each group analyzed). There was no significant difference in the raw redemption rate of e-vouchers between pregnant participants in the intervention group (70%) and the control group (67%). Younger participants were less likely to redeem e-vouchers.

Conclusions: The use of a BCC mobile messaging intervention did not result in a significant increase in LLIN uptake for pregnant individuals. However, the study shows that e-voucher distribution through nurses in antenatal clinics in partnership with local retailers is feasible on a large scale. Consideration of women and adolescents who are low-income and live in rural areas is needed for future interventions leveraging e-vouchers or mHealth technology in low-resource settings.

Trial registration: ClinicalTrials.gov NCT02561624; https://clinicaltrials.gov/ct2/show/NCT02561624.