Using human-centered design to co-design dedicated menstrual health spaces with people who menstruate in Bidi Bidi refugee settlement, Uganda: Learnings for further adaptation and scale in humanitarian settings.

BACKGROUND: Many people who menstruate in low- and middle-income countries struggle to manage their menstruation safely, hygienically, and with dignity. This is exacerbated in humanitarian settings with limited access to menstrual products and safe, private spaces for changing, washing, and disposing of menstrual products. To address these challenges, Youth Development Labs (YLabs) used a human-centered design approach to co-design the Cocoon Mini, a safe, physical structure for managing menstruation in the Bidi Bidi Refugee Settlement in Uganda. METHODS: The study comprised five phases, including background research, design research, rough prototyping, live prototyping, and a pilot study. A total of 340 people, including people who menstruate, male community members, and community stakeholders, participated in interviews, focus groups, and co-design sessions. Solution prototypes were created, evaluated, and iterated upon in each successive project phase. The final intervention design, the Cocoon Mini, was evaluated qualitatively for feasibility and acceptability during a three-month pilot using structured interviews with 109 people who menstruate utilizing Cocoon Mini structures, 64 other community members, and 20 Cocoon Mini supervisors. RESULTS: Results showed widespread desirability and acceptability of the Cocoon Mini among people who menstruate and other community members. Overall, 95% (104/109) of people who menstruate stated the space had made menstrual health management easier, primarily by providing designated waste bins, solar lights, and additional water sources. The Cocoon Mini provided an increased sense of physical and psychological safety in knowing where to privately manage menstruation. Furthermore, the Cocoon Mini demonstrated that an intervention could be run and maintained sustainably at the household level in humanitarian contexts, without continued external stakeholder intervention. Each Cocoon Mini structure costs approximately $360 USD to build and maintain and serves 15-20 people who menstruate, leading to a cost per person of $18-$24. Furthermore, attaching an incinerator to the structure for easier and quicker disposal of waste bin contents (compared to transporting full waste bins elsewhere) costs $2110 USD. CONCLUSIONS: People who menstruate lack access to safe, private spaces for menstrual health and product disposal in humanitarian settings. The Cocoon Mini provides a solution for the safe and effective management of menstruation. Customizing and scaling up dedicated menstrual health spaces should be considered a high-priority intervention in humanitarian settings.

Digital self-care for improved access to family planning and reproductive health services among adolescents in Rwanda: preliminary findings from a pilot study of CyberRwanda.

Adolescents experience significant barriers, including stigma and discrimination, to accessing voluntary family planning and reproductive health (FP/RH) services in Rwanda. Self-care interventions have been shown to reduce social barriers to FP/RH care, but little is known about the effectiveness of digital self-care for adolescents, particularly in low-resource settings. This paper presents findings from a pilot study of CyberRwanda, a digital self-care intervention providing comprehensive sexuality education and confidential online ordering of contraceptives for school-aged youth in Rwanda through a rights-based approach. A mixed-methods pilot study was conducted from November 2019 to February 2020 to assess feasibility, acceptability, and engagement and to inform a future impact evaluation. Surveys were administered to a random sample of 158 students aged 12-19 years in three secondary schools. In-depth interviews were conducted with students, parents, teachers, pharmacists, district-level administrators, and youth centre staff. Descriptive statistics were calculated and qualitative data were analyzed using a thematic coding approach. One hundred and fifty-eight surveys and 28 interviews were conducted. Results revealed high demand for CyberRwanda in schools. Students were interested in engaging with the program and found the FP/RH content relevant to their needs. However, few purchased contraceptive products through the online ordering system. There are preliminary indications that CyberRwanda may improve access to FP/RH information. An extended implementation period and further research are needed to measure the long-term impacts of the program and evaluate whether this digital self-care intervention can increase uptake of contraceptive methods and reduce adolescent pregnancy among school-aged youth.

Using Human-Centered Design to Develop, Launch, and Evaluate a National Digital Health Platform to Improve Reproductive Health for Rwandan Youth.

BACKGROUND: A lack of access to evidence-based, unbiased, and youth-friendly family planning and reproductive health (FP/RH) information and care limit young people's ability to prevent unplanned pregnancies and HIV and sexually transmitted infections. This threat-ens their health and is a significant cause of school drop-out, limiting young peoples' well-being, future potential, and employment opportunities. To address these challenges facing youth, YLabs used an end-to-end human-centered design (HCD) approach to create CyberRwanda, a digital platform aiming to improve the health and livelihoods of adolescents (aged 12-19 years) in Rwanda. DESIGNING FOR DIGITAL WITH YOUTH: From 2016 to 2020, CyberRwanda was designed and piloted using an HCD approach in partnership with more than 1,000 youth, parents, teachers, and public and private health care providers. During the problem recognition phase, HCD revealed participants' beliefs, behavioral preferences, and experiences as they relate to FP/RH specifically and their broader life experiences, motivations, and challenges. Several phases of analog, digital, and live prototyping with youth and key stakeholders were used to codesign, test, and refine the intervention for implementation. RESULTS: CyberRwanda is a direct-to-consumer platform where adolescents can learn integrated, age-appropriate health, and skills-building information through edutainment behavior change stories and a robust frequently asked questions library, order health products online, and be linked to CyberRwanda's network of private and public health care providers who have been trained to provide adolescent-friendly care. IMPLICATIONS FOR FUTURE RESEARCH: The HCD process resulted in significant pivots to the design of the digital platform and the implementation model. Using HCD provided a structured methodology to combine technical FP/RH expertise and visual and product design expertise to codesign and iteratively develop a digital health intervention with and for Rwandan youth.

Mentoring Interventions and the Impact of Protective Assets on the Reproductive Health of Adolescent Girls and Young Women.

Adolescent girls and young women (AGYW) are disproportionately affected by HIV and AIDS and other negative reproductive health (RH) outcomes. Emerging evidence suggests that programs to build AGYW's assets can help reduce their vulnerability to poor RH. Mentoring interventions have demonstrated a positive impact on a variety of youth development outcomes, including the protective assets needed to circumvent poor RH outcomes. The purpose of this review was to understand the types of mentoring programs for AGYW that have demonstrated effectiveness in improving protective assets, and/or, RH knowledge, intentions, behaviors, or outcomes themselves. Interventions were identified through an electronic search of the peer-reviewed and the gray literature. Studies were excluded in stages based on reviews of titles, abstracts, and full text. A review of 491 publications yielded a total of 19 articles that were included in the final review. The majority of the publications examined the impact of the one-to-one mentoring model in the United States. However, a good proportion examined the impact of both one-on-one and group-based interventions globally. The few interventions that followed a group-based model demonstrated more promise; evaluations of this model demonstrated a positive impact on RH knowledge and behavior, academic achievement, financial behavior, and social networks, as well as reductions in the experience of violence. Group-based mentoring programs demonstrated the most promise in building AGYW's protective assets and improving their RH outcomes. The most successful interventions consisted of multiple components, including mentoring, that sought to directly improve AGYW's protective assets and met with more frequency over a longer duration. Despite the promising evidence, more research is needed to better understand the relationship between assets and RH; the characteristics of successful mentoring programs; and the influence mentoring alone has on RH outcomes, versus mentoring as part of a larger RH program.

Meeting the Reproductive Health Needs of Female Key Populations Affected by HIV in Low- and Middle-Income Countries: A Review of the Evidence.

Female sex workers and other women at high risk of acquiring HIV have the right to sexual and reproductive health, including the right to determine the number and timing of pregnancies. We conducted a literature review to examine the data that exist regarding the family planning and reproductive health needs of female key populations, the underlying determinants of these populations' vulnerability to poor reproductive health outcomes, and the obstacles they face in accessing high-quality reproductive health services. Findings indicate that female key populations experience high rates of unmet need for family planning and safer conception services, unintended pregnancies, sexual violence, and abortion, and that they practice inconsistent condom use. Restrictive policy environments, stigma and discrimination in health care settings, gender inequality, and economic marginalization restrict access to services and undermine the ability to safely achieve reproductive intentions. We offer recommendations for structural, health system, community, and individual-level interventions that can mitigate the effects of these barriers and improve reproductive health outcomes.

Meet us on the phone: mobile phone programs for adolescent sexual and reproductive health in low-to-middle income countries.

INTRODUCTION: mHealth as a technical area has seen increasing interest and promise from both developed and developing countries. While published research from higher income countries on mHealth solutions for adolescent sexual and reproductive health (SRH) is growing, there is much less documentation of SRH mHealth interventions for youth living in resource-poor settings. We conducted a global landscape analysis to answer the following research question: How are programs using mHealth interventions to improve adolescent SRH in low to middle income countries (LMICs)? METHODS: To obtain the latest information about mHealth programs targeting youth SRH, a global call for project resources was issued in 2014. Information about approximately 25 projects from LMICs was submitted. These projects were reviewed to confirm that mobile phones were utilized as a key communication media for the program, that youth ages 10-24 were a prime target audience, and that the program used mobile phone features beyond one-on-one phone calls between youth and health professionals. RESULTS: A total of 17 projects met our inclusion criteria. Most of these projects were based in Africa (67%), followed by Eurasia (26%) and Latin America (13%). The majority of projects used mHealth as a health promotion tool (82%) to facilitate knowledge sharing and behavior change to improve youth SRH. Other projects (18%) used mHealth as a way to link users to essential SRH services, including family planning counseling and services, medical abortion and post-abortion care, and HIV care and treatment. There was little variation in delivery methods for SRH content, as two-thirds of the projects (70%) relied on text messaging to transmit SRH information to youth. Several projects have been adapted and scaled to other countries. DISCUSSION: Findings suggest that mHealth interventions are becoming a more common method to connect youth to SRH information and services in LMICs, and evidence is emerging that mobile phones are an effective way to reach young people and to achieve knowledge and behavior change. More understanding is needed about the challenges of data privacy and phone access, especially among younger adolescents, and the role that mHealth solutions for adolescent SRH should play in health programming for young people.

Mobile Phone Interventions for Adolescent Sexual and Reproductive Health: A Systematic Review.

CONTEXT: Interventions for adolescent sexual and reproductive health (ASRH) are increasingly using mobile phones but may not effectively report evidence. OBJECTIVE: To assess strategies, findings, and quality of evidence on using mobile phones to improve ASRH by using the mHealth Evidence Reporting and Assessment (mERA) checklist recently published by the World Health Organization mHealth Technical Evidence Review Group. DATA SOURCES: Systematic searches of 8 databases for peer-reviewed studies published January 2000 through August 2014. STUDY SELECTION: Eligible studies targeted adolescents ages 10 to 24 and provided results from mobile phone interventions designed to improve ASRH. DATA EXTRACTION: Studies were evaluated according to the mERA checklist, covering essential mHealth criteria and methodological reporting criteria. RESULTS: Thirty-five articles met inclusion criteria. Studies reported on 28 programs operating at multiple levels of the health care system in 7 countries. Most programs (82%) used text messages. An average of 41% of essential mHealth criteria were met (range 14%-79%). An average of 82% of methodological reporting criteria were met (range 52%-100%). Evidence suggests that inclusion of text messaging in health promotion campaigns, sexually transmitted infection screening and follow-up, and medication adherence may lead to improved ASRH. LIMITATIONS: Only 3 articles reported evidence from lower- or middle-income countries, so it is difficult to draw conclusions for these settings. CONCLUSIONS: Evidence on mobile phone interventions for ASRH published in peer-reviewed journals reflects a high degree of quality in methods and reporting. In contrast, current reporting on essential mHealth criteria is insufficient for understanding, replicating, and scaling up mHealth interventions.