Evaluating gain and loss-framed mobile messaging to improve maternal health service uptake: A cluster randomized controlled trial in Jimma, Ethiopia
Gebeyehu Bulcha Duguma, Hordofa Gutema, Mulusew Gerbaba, Demisew Amenu, Zewdie BirhanuBackground
Maternal mortality has declined in Ethiopia, yet rural areas still struggle with access to care. Mobile phone-based gain or loss-framed messaging-hold promise for improving maternal health outcomes. Evidence on the comparative impact of these framing strategies in low-resource rural settings remains limited. This study evaluated the effectiveness of gain- versus loss-framed SMS messages in improving maternal health service utilization in Jimma Zone, Ethiopia.
Methods
A three-arm cluster-randomized controlled trial was conducted across 21 clusters, with clusters allocated to gain-framed messaging, loss-framed messaging, or control (usual care). A total of 588 pregnant women (16–20 GA) were recruited in March 2023 and followed from May to December 2023, with endline assessment in February 2024. Participants received 39 messages over a 6–8 month period, aligned with gestational age and postnatal timeline. Primary outcomes were at least one ANC, SBA, and PNC within 7 days. Secondary outcomes included knowledge, attitudes, self-efficacy, and self-reported morbidity. Analyses used generalized and linear mixed models with cluster-level adjustments.
Result
Both framing strategies improved service utilization compared to control. Gain-framed messages increased odds of ANC attendance (OR 5.40, 97.5% CI 1.95–14.94), SBA (OR 7.53, 97.5% CI 2.20–25.79), and PNC (OR 4.83, 97.5% CI 1.71–13.67). Loss-framed messages also improved ANC attendance (OR 7.14, 97.5% CI 2.40–21.26), Skilled Birth Attendance (SBA) (OR 7.31, 97.5% CI 2.13–25.09), and PNC (OR 4.07, 97.5% CI 1.46–11.39). Knowledge improved in both arms, attitudes improved only in the gain-framed arm, and self-efficacy showed no significant change. Self-reported maternal morbidity decreased in both intervention arms.
Conclusion
Both gain- and loss-framed mobile messages led to increased maternal health service utilization. Loss-framed messages were more effective for ANC attendance, knowledge, and morbidity reduction, while gain-framed messages showed greater impact on SBA, PNC, and attitudes.
Trial registration
Pan African Clinical Trials Registry (PACTR), PACTR202201753436676, registered on January 4, 2022;