Young people’s experiences using an on-demand mobile health sexual and reproductive health text message intervention in Kenya : qualitative study

Background: Digital health usability assessments can help explain how well mobile health (mHealth) apps targeting young people with sexual and reproductive health (SRH) information performed and whether the intended purpose was achieved. However, few digital health assessments have been conducted to evaluate young people’s perceptions regarding mHealth system interactions and content relevance on a wide range of SRH topics. In addition, the majority of randomized controlled trials (RCTs) have focused on push messaging platforms; therefore, the mHealth field lacks sufficient RCTs investigating on-demand mHealth SRH platforms. Objective: The objective of this study was to explore young people’s experiences using an on-demand SRH mHealth platform in Kenya. Methods: We used qualitative data related to the usability of an mHealth platform, Adolescent/Youth Reproductive Mobile Access and Delivery Initiatives for Love and Life Outcome (ARMADILLO), collected at the end of the intervention period. A total of 30 in-depth interviews (IDIs) were held with the intervention participants (15 women and 15 men) to elicit their experiences, opinions, and perspectives on the design and content of the ARMADILLO platform. The study participants were randomly selected from a list of intervention arm participants to participate in the IDIs. The interviews were later transcribed verbatim, translated into English, and coded and analyzed thematically using NVivo version 12 software (QSR International). Results: Respondents reported varied user experiences and levels of satisfaction, ranging from ease of use by the majority of the respondents to systematic frustrations that prevented some participants from progressing to other stages. Interesting features of the mHealth platform included the immediate response participants received when requesting messages, weekly remunerated quizzes, and perceived ability of educative and informative content and messages to change behaviors. Proposed enhancements to the platform included revising some concepts and words for easy understanding and increasing the interactivity of the platform, whereby young people could seek clarity when they came across difficult terms or had additional questions about the information they received. Conclusions: The importance of understanding the range of health literacy and technological variations when dealing with young people cannot be overemphasized. Young people, as mHealth end users, must be considered throughout intervention development to achieve optimum functionality. In addition, young people targeted with mHealth SRH interventions must be sensitized to the interactions on mHealth platforms or any other digital health apps if implemented in a nonresearch setting for optimal use by the targeted audience

Research and implementation lessons learned from a youth-targeted digital health randomized controlled trial (the ARMADILLO Study)

Evidence is lacking on the efficacy of sexual and reproductive health (SRH) communication interventions for youth (aged 15-24 years), especially from low- and middle-income countries. Therefore, the World Health Organization initiated the Adolescent/Youth Reproductive Mobile Access and Delivery Initiative for Love and Life Outcomes (ARMADILLO) program, a free, menu-based, on-demand text message (SMS, short message service) platform providing validated SRH content developed in collaboration with young people. A randomized controlled trial (RCT) assessing the effect of the ARMADILLO intervention on SRH-related outcomes was implemented in Kwale County, Kenya.; This paper describes the implementation challenges related to the RCT, observed during enrollment and the intervention period, and their implications for digital health researchers and program implementers.; This was an open, three-armed RCT. Following completion of a baseline survey, participants were randomized into the ARMADILLO intervention (arm 1), a once-a-week contact SMS text message (arm 2), or usual care (arm 3, no intervention). The intervention period lasted seven weeks, after which participants completed an endline survey.; Two study team decisions had significant implications for the success of the trial's enrollment and intervention implementation: a hands-off participant recruitment process and a design flaw in an initial language selection menu. As a result, three weeks after recruitment began, 660 participants had been randomized; however, 107 (53%) participants in arm 1 and 136 (62%) in arm 2 were "stuck" at the language menu. The research team called 231 of these nonengaging participants and successfully reached 136 to learn reasons for nonengagement. Thirty-two phone numbers were found to be either not linked to our participants (a wrong number) or not in their primary possession (a shared phone). Among eligible participants, 30 participants indicated that they had assumed the introductory message was a scam or spam. Twenty-seven participants were confused by some aspect of the system. Eleven were apathetic about engaging. Twenty-four nonengagers experienced some sort of technical issue. All participants eventually started their seven-week study period.; The ARMADILLO study's implementation challenges provide several lessons related to both researching and implementing client-side digital health interventions, including (1) have meticulous phone data collection protocols to reduce wrong numbers, (2) train participants on the digital intervention in efficacy assessments, and (3) recognize that client-side digital health interventions have analog discontinuation challenges. Implementation lessons were (1) determine whether an intervention requires phone ownership or phone access, (2) digital health campaigns need to establish a credible presence in a busy digital space, and (3) interest in a service can be sporadic or fleeting.; International Standard Randomized Controlled Trial Number (ISRCTN): 85156148; http://www.isrctn. com/ISRCTN85156148

Exploring contraception myths and misconceptions among young men and women in Kwale County, Kenya

BackgroundMyths and misconceptions around modern contraceptives have been associated with low contraceptive uptake in sub-Saharan Africa and Kenya in particular. Addressing persistent contraceptive knowledge gaps can make a significant contribution towards improved contraceptive uptake among young women. This qualitative study therefore sought to explore and understand young people's knowledge of modern contraception and to identify their key concerns regarding these methods.MethodsWe used focus group discussions (FGD) with vignette and writing activities to explore key myths and misconceptions around the use of contraceptives. Six FGDs (three for young men and three for young women) were conducted with a total of 28 young women and 30 young men from Kwale County, Kenya. We included 10 discussants aged 18-24 per FGD, one FGD had 8 participants. Predefined codes reflecting the discussion guides and emerging issues in the FGDs were used to develop the thematic coding framework. Our analysis followed a pattern of association on the key preset themes focusing on myths and misconceptions around contraceptive use.ResultsResults are presented under four key themes: awareness of contraception, myths and misconceptions around contraception, males' contraceptive narratives and young people's preferred sources of contraceptives. Both men and women participants reported basic awareness of contraceptives. A mixture of biological and social misconceptions were discussed and included perceptions that modern contraception: jeopardized future fertility, could result in problems conceiving or birth defects, made women promiscuous, was 'un-African', and would deny couples their sexual freedom. Compared to female respondents in the study, young men appeared to be strong believers of the perceived socio-cultural effects of contraceptives. On preferred sources of contraceptives, respondents reported on two main sources, pharmacies and public hospitals, however, they could not agree on which one was suitable for them.ConclusionsThis study revealed the presence of a mixture of biological and social myths and misconceptions around contraception, with young men also strongly adhering to these misconceptions. The low level of contraceptive knowledge, particularly on contraceptive fears as revealed by the study demonstrate critical gaps in sexual and reproductive health (SRH) knowledge among young people. Improved SRH literacy to address contraceptives' fears through appropriate and gender specific interventions to reach out to young men and women with factual SRH information may therefore contribute to increased uptake of SRH services including modern contraceptive methods

Busting contraception myths and misconceptions among youth in Kwale County, Kenya: results of a digital health randomised control trial

Objectives: The objective of this randomised controlled trial in Kenya was to assess the effect of delivering sexual and reproductive health (SRH) information via text message to young people on their ability to reject contraception-related myths and misconceptions. Design and setting: A three-arm, unblinded randomised controlled trial with a ratio of 1:1:1 in Kwale County, Kenya. Participants and interventions: A total of 740 youth aged 18–24 years were randomised. Intervention arm participants could access informational SRH text messages on-demand. Contact arm participants received once weekly texts instructing them to study on an SRH topic on their own. Control arm participants received standard care. The intervention period was 7 weeks. Primary outcome: We assessed change myths believed at baseline and endline using an index of 10 contraception- related myths. We assessed change across arms using difference of difference analysis. Results: Across arms, \u3c5% of participants did not have any formal education, \u3c10% were living alone, about 50% were single and \u3e80% had never given birth. Between baseline and endline, there was a statistically significant drop in the average absolute number of myths and misconceptions believed by intervention arm (11.1%, 95% CI 17.1% to 5.2%), contact arm (14.4%, 95% CI 20.5% to 8.4%) and control arm (11.3%, 95% CI 17.4% to 5.2%) participants. However, we observed no statistically significant difference in the magnitude of change across arms. Conclusions: We are unable to conclusively state that the text message intervention was better than text message ‘contact’ or no intervention at all. Digital health likely has potential for improving SRH-related outcomes when used as part of multifaceted interventions. Additional studies with physical and geographical separation of different arms is warranted

Evidence on respectful maternity care for adolescents: A systematic review protocol

Background: Intrapartum mistreatment of women is an ubiquitous public health and human rights challenge. The issue reportedly has severe maternal and neonatal outcomes including mortality, and generally leads to a decreased satisfaction with maternity care. Intrapartum mistreatment, despite being ubiquitous, indicates higher incidence amongst adolescent parturients who are simultaneously at a higher risk of maternal morbidity and mortality. Studies have suggested that Respectful Maternity Care interventions reduce intrapartum mistreatment and improve clinical outcomes for women and neonates in general. However, evidence on the effect of RMC on adolescents is unclear. Hence, the specific aim of this study is to synthesise the available evidence relating to the provision of RMC for adolescents during childbirth. Methods: The methodology of the proposed systematic review follows the procedural guideline depicted in the preferred reporting items for systematic review protocol. The review will include published studies and gray literature from January 1, 1990, to June 30, 2021. Electronic databases including MEDLINE, PubMed, ScienceDirect, Cochrane, CINAHL, PsycINFO, Scopus, Google Scholar and Web of Science will be searched to retrieve available studies using the appropriate search strings. Studies included in the review will be appraised for quality using tools tailored to each study design. If appropriate, we will conduct random effects meta-analysis of data to summarise the pooled estimates of respectful maternity care prevalence and outcomes. The selection of relevant studies, data extraction and quality assessment of individual studies will be carried out by two independent authors. Results: Summaries of the findings will be compiled and synthesised in a narrative summary. In addition to the narrative synthesis, where sufficient data are available, a random-effects meta-analysis will be conducted to obtain a pooled estimate value for respectful maternity care prevalence and outcomes. Discussion: Respectful Maternity Care for adolescents holds great promise for improved maternal and neonatal care. However, there is a gap in knowledge on the interventions that work and the extent of their effectiveness. Findings from this study will be beneficial in improving Adolescents Sexual and Reproductive Health and Rights and reducing maternal mortality, especially for adolescents

Evaluation of the ELIMIKA pilot project : improving ART adherence among HIV positive youth using an eHealth intervention in Mombasa, Kenya

Adolescents and young people are arguably the most dynamic and challenging group among populations living with HIV. The adherence to anti-retroviral treatment (ART) is often low among HIV-positive youth, thus creative and context specific interventions are necessary. We aimed at evaluating the usability and effectiveness of the pilot digital peer support platform – ELIMIKA, implemented in Mombasa, Kenya. We applied a pre-post-test design. Data collection consisted of two parts: pre- and post-online knowledge and behavior questionnaires, and a mid-term usability survey. From 90 recruited participants, 81 completed the pre- and post-questionnaires. Overall, the participants were satisfied with the main features of the web platform and stated that they would use it again (95%). However, there was not a significant change in knowledge and behavior, but adherence intentions after 3 months intervention period have improved. This study provides valuable information on feasibility, evaluation and challenges of eHealth intervention in Kenya that supports further research in this area

Failing the rights: sexual vulnerability, access to services and barriers to contraceptives among adolescents in Narok County, Kenya

Purpose: Around one in five girls in Kenya, aged 15 to 19 years old are either pregnant or have given birth. Of 47 counties, adolescent pregnancy is highest in Narok, where about 40% of girls aged 15 to 19 years old have begun childbearing. This study aims to explore drivers to sexual activity, access to sexual and reproductive health (SRH) services and barriers to contraceptive use among adolescents in Narok County, Kenya to inform the design of SRH interventions and safeguard young people’s rights to sexual health. Design/methodology/approach: A cross-sectional mixed methods study was conducted in December 2019. Quantitative data were collected through structured questionnaires among girls aged 15 to 19 years old who were either pregnant or had given birth and those who had not and boys aged 15 to 19 years old. Qualitative data were collected through focus group discussions with adolescent girls and boys and through structured key informant interviews with parents, community leaders and health workers. Findings: The mean age at first sexual intercourse for both genders was 15 years. While the majority of girls and boys knew where to access SRH services, few used contraception during their last sexual activity. There was no significant difference in the condom or other contraceptive methods use between girls who had begun child bearing and those who had not (p = 0.549 and p = 0.563, respectively). Key drivers for sexual activity among young people were poverty and peer pressure. Cultural practices such as female genital mutilation and early marriage contributed to early sex. Community attitudes toward contraception discouraged young people from taking up contraceptives. Originality/value: This mixed methods study explores the drivers of adolescent pregnancy in Narok, Kenya, the county with the highest rates of adolescent pregnancy; twice the national pregnancy rates. Understanding the drivers of pregnancy and the underlying human rights violations will help policymakers and health leaders to design interventions which will improve outcomes

Protocol of an open, three-arm, individually randomized trial assessing the effect of delivering sexual and reproductive health information to young people (aged 13–24) in Kenya and Peru via mobile phones: adolescent/youth reproductive mobile access and delivery initiative for love and life outcomes (ARMADILLO) study stage 2

Resumen Antecedentes Las personas jóvenes se enfrentan a desafíos únicos en cuanto a acceso a información y apoyo en temas de salud sexual y reproductiva (SSR). Debido a su elevada penetración y acceso, los teléfonos celulares brindan un nuevo canal para acceder a los jóvenes. Sin embargo, existe poca evidencia sobre el impacto de las intervenciones digitales en la mejora de los resultados de salud. La investigación ARMADILLO (Adolescent/Youth Reproductive Mobile Access and Delivery Initiative for Love and Life Outcomes en inglés y Uso de celulares para mejorar resultados de amor y vida en adolescentes y jóvenes en español) evaluará el efecto de una intervención que brinda información sobre SSR a jóvenes mediante mensajes de texto a sus celulares en Kenia y Perú. Este protocolo detalla un ensayo abierto de tres brazos aleatorizado a nivel individual que dura siete semanas y evalúa el efecto de la intervención ARMADILLO para disipar los mitos e ideas equivocadas relacionadas a los métodos anticonceptivos. Un objetivo secundario es determinar si los jóvenes que tienen acceso a información sobre SSR vía mensaje de texto pueden retener esa información de manera precisa. Métodos Posterior a una enumeración de hogares, una persona joven por cada hogar será seleccionada al azar para ser participante y será randomizada por computadora en uno de los tres brazos. Los participantes del brazo intervención recibirán acceso a los contenidos de ARMADILLO, los participantes del brazo control no recibirán ninguna información, y los participantes del ‘brazo 3’ variarán según la sede: en Kenia, serán alertados sobre diversos dominios de SSR y animados a aprender más por su cuenta; en Perú, recibirán contenidos claves de cada dominio con la opción de aprender más si desean. Los participantes completarán encuestas de opción múltiple administradas por encuestadores durante la línea basal (antes de ser randomizados), al final de la intervención (después de la semana 7), y ocho semanas después de terminar la intervención. Discusión Parte del compromiso de los Objetivos de Desarrollo Sostenible hacia garantizar una vida sana y promover el bienestar para todos en todas las edades incluye un compromiso a ‘garantizar el acceso universal a los servicios de salud sexual y reproductiva, incluidos los de planificación de la familia, información y educación’. Si se prueba su efectividad, intervenciones como ARMADILLO podrían tender un puente sobre una brecha importante hacia el logro del acceso universal a información y educación en SSR para un grupo que es difícil de alcanzar de otra manera. Registro del Ensayo Este ensayo se registró de manera retrospectiva con el Registro ISRCTN y fue asignado el número de registro ISRCTN85156148 el 29 de mayo, 2018

Busting contraception myths and misconceptions among youth in Kwale County, Kenya : results of a digital health randomised control trial

Objectives The objective of this randomised controlled trial in Kenya was to assess the effect of delivering sexual and reproductive health (SRH) information via text message to young people on their ability to reject contraception-related myths and misconceptions. Design and setting A three-arm, unblinded randomised controlled trial with a ratio of 1:1:1 in Kwale County, Kenya. Participants and interventions A total of 740 youth aged 18-24 years were randomised. Intervention arm participants could access informational SRH text messages on-demand. Contact arm participants received once weekly texts instructing them to study on an SRH topic on their own. Control arm participants received standard care. The intervention period was 7 weeks. Primary outcome We assessed change myths believed at baseline and endline using an index of 10 contraception-related myths. We assessed change across arms using difference of difference analysis. Results Across arms, 80% had never given birth. Between baseline and endline, there was a statistically significant drop in the average absolute number of myths and misconceptions believed by intervention arm (11.1%, 95% CI 17.1% to 5.2%), contact arm (14.4%, 95% CI 20.5% to 8.4%) and control arm (11.3%, 95% CI 17.4% to 5.2%) participants. However, we observed no statistically significant difference in the magnitude of change across arms. Conclusions We are unable to conclusively state that the text message intervention was better than text message 'contact' or no intervention at all. Digital health likely has potential for improving SRH-related outcomes when used as part of multifaceted interventions. Additional studies with physical and geographical separation of different arms is warranted