In Nicaragua, sex is embarrassing. Yet in a country where approximately 50 percent of the population is below the age of 18, and where 1 in 3 adolescent girls will become pregnant before they reach the age of 18, it’s clear that people are having sex—they’re just not talking about it due to pena—a wonderfully ambiguous word located somewhere between shame, embarrassment, and awkwardness.
When the only way to access reliable sexual and reproductive health information is through a face-to-face consultation with the community doctor or nurse, it’s not surprising that most people opt to get their sexual health information from “la calle”—or rather, from friends and family who may not have complete or accurate information. Rural populations are hesitant to consult with a doctor due to the perception that the community will find out and think of them as promiscuous, unfaithful, or diseased. As a result, misinformation about sexual health is rampant, especially among youth.
The ChatSalud team is comprised of Nicaraguans from various institutions, as well as Peace Corps Volunteers who are living and working in rural Nicaragua, in places ranging from the northern-most mountains all the way to the Río San Juan. From these collective experiences, certain realities have become abundantly clear to us: 1) there is a high rate of young girls getting pregnant; 2) women are at high-risk for developing preventable diseases, such as cervical cancer, due to cultural barriers to getting screened; 3) sexually transmitted infections often go untreated; 4) and lastly, more people have access to cell phones than to indoor plumbing.
Accordingly, ChatSalud aims to provide rural text-based education in order to empower Nicaraguans to advocate for their sexual and reproductive health, which will lead to positive behavior change such as increased condom usage, more testing for HIV and other STIs, and learning to use cell phones to access and share information regarding their sexual and reproductive health.
ChatSalud will work as a "ping-pong" system, which is designed to be interactive in nature so that the user can customize their experience with the platform, deciding which information to read and which to skip, based on a series of menus and coded themes. Our “ping-pong” system is modeled after FHI 360’s Mobile for Reproductive Health project in Kenya and Tanzania, though ChatSalud will differ in that it will cover a wider range of themes, ranging from HIVaids, sexually transmitted infections, reproductive health, and safer sexual practices.
The user will initiate the interaction with ChatSalud after viewing an advertisement such as a poster, radio spot, or television ad, or through talking with friends and family that have used the system. The user will send “info” to ChatSalud and will automatically receive an initial menu that will include the four umbrella themes: HIVaids, sexually transmitted infections, reproductive health, and safer sexual practices. From there, the user can choose which theme to learn about. All of the themes are coded by number in the ChatSalud system. The coded automatic responses will give rural Nicaraguans low-tech, text-based access to a plethora of information—essentially a sexual and reproductive health encyclopedia at their fingertips.
ChatSalud is quickly becoming a national-level mobile health platform. While we used a modem for initial tests with limited users, the modem began experiencing a lag time of upwards of 45 minutes. Since we are expecting a high volume of SMS traffic, the throughput required will be significantly more than could be provided by a modem.
Obviously a new system was needed.
While still in development, the new system, which will utilize FrontlineSMS Version 2 mounted on servers and remote browser-based access, will bring together resources provided by several local stakeholders. CIES, the Nicaraguan School of Public Health, will donate and maintain their servers, which will house the FrontlineSMS version 2 software. Meanwhile, a local tech firm, GüeGüe, will provide technical support and assistance to secure and maintain a VPN between the software housed at CIES and the local telecommunications network. The VPN will provide key links to both Claro and Movistar, the local telecommunications providers, and from there, connect to users nation-wide. While the old system could only send and receive six text messages per minute, this new system will have the ability to handle millions of text messages per day, ensuring a smooth and instantaneous interaction between ChatSalud and its users.
In order to gain governmental support, one of the major barriers we had to overcome was to figure out how to make the system 100% anonymous. Normally, when a user communicates with ChatSalud, their personal phone number is displayed along with their message. While we cannot use cell phone numbers and maintain anonymity, an identifying feature was still necessary to allow us to analyze our user interactions. We were lucky to connect with developer Alex Galonsky, who generously donated his time to help us modify the program. Alex's solution was to hash the phone numbers of users as they come in to effectively create a "digital fingerprint" of each user without allowing system operators to view user phone numbers directly on the main interface. This allows us to provide basic anonymity to all users while still monitoring and evaluating the project’s effectiveness. This will also ensure confidentiality if we use the platform to open up direct communication between users and health workers in the future.
We are almost ready to launch ChatSalud. Before we can do so, we must secure funding to cover our SMS expenses. In spite of this remaining hurdle, with each passing week, we are gaining more and more momentum from local stakeholders. With our system in place and nearly ready to go, we hope to launch ChatSalud in the next couple months and start making an impact in the lives of Nicaraguans.