Every day, a large number of women and newborns die from preventable causes related to pregnancy and childbirth, where 94% of all maternal and neonatal deaths occur in low- and middle-income countries (1–3). Maternal and newborn deaths occur mainly from preventable causes, such as infectious diseases and complications during pregnancy, labor, childbirth, and the postpartum period (4). Despite the government’s commitment to improving maternal newborn health (5), Ethiopia is among the top countries in terms of maternal and neonatal mortality rates (3). Providing education to mothers during the antenatal and postnatal periods has effectively improved maternal and neonatal health service utilization and newborn care practices (6) and reduced overall neonatal mortality (7).
Introducing new strategies such as mHealth is accepted as a suitable means for reducing high maternal and child death rates in low-income nations (8, 9). From mHealth technology, short message service (SMS) is an acceptable and widely used tool for educating mothers to promote antenatal delivery, newborn care, and postnatal care utilization (10, 11). SMS-based intervention has been successfully implemented and has indicated promising outcomes in promoting maternal and child health care services (12–15) due to its greater readership and greater engagement advantage over other means of communication (16), providing short, timely information for behavior change (17). Text message-based interventions should incorporate how the message is developed on its theoretical basis, cultural adaptation to the end user, and context before it is implemented (18, 19) for utility (20, 21).
Although it is recommended to start documenting the development of any mHealth-based intervention planned to promote behavior changes during the early stages of the protocol (22), evidence of the content development process and testing methods are limited and underreported in the literature (19, 23). Among the published text messaging interventions that describe development and testing processes, some lack detailed information about the process (19, 24), and others focus on the messaging system development process, ignoring the message content (25).
For a successful SMS-based intervention, the target audience should provide feedback on the message content and learn the language preferences, timing, and number of text messages they receive (12, 26). End-user involvement in the mHealth intervention development process facilitates the feasibility, acceptability, and engagement of the intervention (27). In addition, health workers' expectations and readiness to implement the suggested interventions when developing digital interventions are needed (28). The perspectives of these end users and implementers can be addressed by applying a user-centered design approach (29). User-centered design is a multidisciplinary and iterative design approach based on the active involvement of users in each phase of the design process to improve the understanding of users and requirements (30). This approach uses methods such as focus group discussion, survey, interview, usability testing, card sorting, and participatory design. However, there is inconsistency in the utilization of these methods; for example, some researchers have used card sorting with end users (29, 31, 32), others have used expert evaluation (23, 29, 33–35), while focus group discussion (23, 35, 36) and pilot with members of the end user (29, 37, 38) have been used by some of the researchers. Moreover, to our knowledge, none of the mHealth interventions conducted in Ethiopia reported the development and testing of message content tailored to the local context.
Considering the variation in the methods used and the limited literature on the design and development of mobile phone-based messaging interventions for improving maternal and newborn health in rural areas of Ethiopia, this study presents the development and testing process by integrating different methods previously used. The message content was drafted based on the concept of framing. Framing is the way information is presented to individuals by emphasizing the benefits of taking action (i.e., a gain-framed) or the costs of failing to take action (i.e., a loss-framed message) to influence subsequent decisions of individuals (39). Hence, the current development process was carried out by integrating user-centered design approach methods: card sorting, interviews, pilot testing, system usability testing and expert review. In addition to adding the mobile phone-based messaging intervention development process to the body of knowledge, this study provides recommendations and lessons learned from the process for similar interventions targeting pregnant mothers.