Exploring the Use of Technology for Sexual Health Risk-Reduction among Ecuadorean Adolescents

Background: There is a lack of sexual health knowledge and resource access among youth in Latin America, along with rising rates of teenage pregnancy and STD transmission. Objective: To determine baseline sexual health knowledge and the acceptance of a technology based sexual health risk-reduction program among Ecuadorean adolescents. Methods: We used mixed methods to determine the sexual health knowledge and practices, and technology use among 204 adolescents from two schools in Cumbayá and Lumbisí, Ecuador. Quantitative data was collected through surveys and qualitative through single-gender focus groups. Findings: Nearly every participant (96.6%) expressed interest in a sexual health education program using technology and social media. A majority of participants indicated that they consulted parents (58.3%) regarding sexual health questions. Only a few participants had access to physicians outside of appointments (3.9%), and most desired more sexual health information (87.3%). Although approximately one-quarter of participants were sexually active (27%), most lacked baseline knowledge regarding contraceptives and STDs. Facebook (91%) and WhatsApp (53%) were the most frequently used and requested social media for an educational program. Students indicated a strong desire to be involved in the design stages of a sexual health risk-reduction program, rather than use a pre-established program. Conclusions: There is strong interest in a technology based sexual health risk-reduction program through Facebook and WhatsApp, which could establish communication between health providers and Ecuadorian youth to disseminate health information and answer private inquiries. Findings from this study, the first of its kind among South American adolescents, introduces a novel idea: involving participants from initial design stages of a text-messaging health education program. Future studies should focus on engaging families as well as physicians’ willingness to participate. Implications and Contributions: This paper is the first acceptability study of a technology based sexual health risk-reduction program among low-income South American adolescents. Findings enhance understanding of pregnancy and STD prevention interventions by demonstrating participants’ desire for self-design and implementation, and highlight their importance through a lack of baseline adolescent sexual health knowledge

The effect of a text-messaging intervention on retention in care for women living with HIV and their infants in Kenya

Background: Retention in prevention of mother-to-child transmission (PMTCT) of HIV care is crucial to reduce vertical HIV transmission, and to improve the health and survival of women living with HIV and their infants. HIV-related stigma, social concerns, and non-disclosure of HIV status are barriers to participate in PMTCT care, which potentially could be addressed by supporting women with an interactive text-messaging intervention. The aim of this thesis was to increase knowledge of the effect of an interactive text-messaging intervention on retention in PMTCT care, and to shed light on pregnant women’s HIV status disclosure and their social and emotional barriers to participate in PMTCT care in Kenya. Methods: We recruited pregnant women living with HIV to a randomised controlled trial at six antenatal care clinics in western Kenya between June 2015 to July 2016. The participants in the intervention group received weekly text messages until 24 months postpartum, to which they were requested to respond within 48 hours if they were okay or if they had a problem. Interview data collected at study enrolment at four of the clinics were used to investigate participants’ social concerns to participate in PMTCT care and their association to HIV status disclosure (paper I). We compared the uptake of early infant HIV testing (paper II), and 18-month retention in PMTCT care (paper III) between the intervention and control group at all six clinics. We also investigated women’s adherence to respond if they were okay or had a problem in a cohort study of the intervention group participants (paper IV). Results: In paper I, we observed that 80% of the women who were married or living with a partner had disclosed their HIV status to their partner. Women 35-44 years old had lower odds of HIV status disclosure to a partner (odds ratio [OR]: 0.15; 95% confidence interval [CI]: 0.05-0.44) compared to women 18-24 years old. Women reporting concerns about isolation or lack of support from family or friends (OR: 0.33; 95% CI: 0.12-0.85), separation from a partner (OR: 0.17; 95% CI: 0.05-0.57), or conflict with a partner (OR: 0.18; 95% CI: 0.05-0.67) had lower odds of HIV disclosure to a partner. In paper II we observed no effect of interactive text messaging on uptake of early infant HIV testing in the intervention group compared to the control group (rate ratio [RR]: 0.99; 95% CI: 0.90-1.10; p=0.89). In paper III, 18-month retention in care was similar in the intervention (70%) and the control group (69%) (RR: 1.02; 95% CI: 0.92-1.14; p=0.70). In paper IV we observed that women in the intervention group responded to 49% of the text messages sent to them (48% were okay responses and 1% were problem responses). Women 18-24 years old (OR: 2.20; 95% CI: 1.03-4.72) were more likely to respond to <50% of the text messages compared to women 35-44 years old. Women with higher education (OR: 0.28; 95% CI: 0.13-0.64) were less likely to respond to <50% of the text messages compared to women with lower education. Among the 59% of women who were interviewed at the end of the intervention, 95% reported that the intervention had been helpful, mainly by improving access to and communication with healthcare providers. Conclusion: Younger women were more likely to disclose their HIV status to a partner, possibly indicating lower HIV-related stigma in younger generations in Kenya. However, our results suggest that concerns about isolation, lack of support, separation, and conflict with a partner still prevail and may be barriers that should be addressed to further increase women’s HIV status disclosure to partners. Our results suggest that interactive text messaging does not improve the uptake of early infant HIV testing or 18-month retention in PMTCT care. The modest use of the intervention to report a problem and sending weekly responses, particularly among women of lower education and younger age, should be considered in the design of future interventions aiming to improve outcomes of PMTCT care. Interactive text messaging may be useful to improve access to and communication with healthcare providers for women in PMTCT care

Changing young people's attitudes towards effective contraception using mobile phone messaging

Background: This thesis involved the development and evaluation of a contraceptive behavioural intervention delivered by mobile phone for young people in Tajikistan, Palestine and Bolivia. Methods: The intervention was developed using behavioral science and evaluated by randomised controlled trial in each country. Outcome data were self-reported at four months. The primary outcome was acceptability of at least one method of effective contraception (N = 570 in Palestine and Tajikistan). In Bolivia, a co-primary outcome was use of effective contraception (N = 1310). Secondary and process outcome data were collected. I conducted a post-hoc change from baseline to follow-up analysis in Tajikistan and Bolivia. Interviews with trial participants were also conducted. Results: Intervention development: the results of the intervention development were similar across the countries. The interventions consist of short messages delivered over four months and include the same ten behaviour change methods. Tajikistan trial: 573 were enrolled and 82% (n = 472) completed follow-up. Intervention content was included on the app, causing contamination. Acceptability: 66% intervention vs 64% control; adjusted OR 1.21 95% CI .80-1.83, p = 0.36. Increase in acceptability from baseline to follow-up: 2% to 65%, p < 0.001. Palestine trial: 578 were enrolled and 80% (n = 464) completed follow-up. Acceptability: 31% intervention vs 17% control; adjusted OR 2.34, 95% CI 1.48-3.68, p < 0.001. Bolivia trial: 640 were enrolled and 67% (n = 429) completed follow-up. Use: 37% intervention vs 33% control; adjusted OR 1.19, 95% CI .80-1.77, p = 0.40. Acceptability: 71.92% intervention vs 62.56% control; adjusted OR 1.49, 95% CI .98-2.28, p = 0.06. Increase in acceptability from baseline to follow-up: 9% to 67%, p < 0.001. Interviews: interviewees highly valued the intervention. Conclusion: The interventions were well-specified, theory-based and tailored to each country. It is likely that the intervention delivered by short messages improves attitudes towards effective contraception