Digital training for self-injectable contraceptives: a feasibility and acceptability pilot study.

BACKGROUND: Self-injectable contraceptives, namely subcutaneous depot medroxyprogesterone acetate 104 mg micronised formulation delivered via uniject system, reduce the need to travel to a facility for contraceptive access, but the initial, in-person, training may be a barrier to starting this method. This article reports on a small, exploratory pilot in Kenya to test the feasibility and acceptability of digital self-injection training. METHODS: Participants (n=11) who were currently using injectable contraceptives, intramuscular depot medroxyprogesterone acetate 150 mg injected by a healthcare worker, received digital self-injection training from a trained clinician via a WhatsApp video call. Participants administered a simulated self-injection on a model and an actual self-injection (under supervision) on themselves. The participants' self-injection proficiency, a measure of the feasibility of remote training, was documented using a checklist, and participants were administered a questionnaire about their training experience. The training was observed, and content analysis was used to understand the functionality of training. RESULTS: All participants were proficient when performing the self-injection on themselves after receiving the remote training and reported that the training was acceptable. A barrier to training via a video call was lack of access to quality digital devices. Eight training 'lessons learnt' emerged from the training observations. CONCLUSIONS: Training participants to administer self-injectable contraceptives via WhatsApp video call was feasible and acceptable. Training lessons learnt offer pragmatic adaptations for communicating about a practical skill via a digital channel. Further research is needed to ascertain the efficacy of digital training for self-injection and feasibility and acceptability for wider groups.

Chatbots That Deliver Contraceptive Support: Systematic Review.

BACKGROUND: A chatbot is a computer program that is designed to simulate conversation with humans. Chatbots may offer rapid, responsive, and private contraceptive information; counseling; and linkages to products and services, which could improve contraceptive knowledge, attitudes, and behaviors. OBJECTIVE: This review aimed to systematically collate and interpret evidence to determine whether and how chatbots improve contraceptive knowledge, attitudes, and behaviors. Contraceptive knowledge, attitudes, and behaviors include access to contraceptive information, understanding of contraceptive information, access to contraceptive services, contraceptive uptake, contraceptive continuation, and contraceptive communication or negotiation skills. A secondary aim of the review is to identify and summarize best practice recommendations for chatbot development to improve contraceptive outcomes, including the cost-effectiveness of chatbots where evidence is available. METHODS: We systematically searched peer-reviewed and gray literature (2010-2022) for papers that evaluated chatbots offering contraceptive information and services. Sources were included if they featured a chatbot and addressed an element of contraception, for example, uptake of hormonal contraceptives. Literature was assessed for methodological quality using appropriate quality assessment tools. Data were extracted from the included sources using a data extraction framework. A narrative synthesis approach was used to collate qualitative evidence as quantitative evidence was too sparse for a quantitative synthesis to be carried out. RESULTS: We identified 15 sources, including 8 original research papers and 7 gray literature papers. These sources included 16 unique chatbots. This review found the following evidence on the impact and efficacy of chatbots: a large, robust randomized controlled trial suggests that chatbots have no effect on intention to use contraception; a small, uncontrolled cohort study suggests increased uptake of contraception among adolescent girls; and a development report, using poor-quality methods, suggests no impact on improved access to services. There is also poor-quality evidence to suggest increased contraceptive knowledge from interacting with chatbot content. User engagement was mixed, with some chatbots reaching wide audiences and others reaching very small audiences. User feedback suggests that chatbots may be experienced as acceptable, convenient, anonymous, and private, but also as incompetent, inconvenient, and unsympathetic. The best practice guidance on the development of chatbots to improve contraceptive knowledge, attitudes, and behaviors is consistent with that in the literature on chatbots in other health care fields. CONCLUSIONS: We found limited and conflicting evidence on chatbots to improve contraceptive knowledge, attitudes, and behaviors. Further research that examines the impact of chatbot interventions in comparison with alternative technologies, acknowledges the varied and changing nature of chatbot interventions, and seeks to identify key features associated with improved contraceptive outcomes is needed. The limitations of this review include the limited evidence available on this topic, the lack of formal evaluation of chatbots in this field, and the lack of standardized definition of what a chatbot is.

Opening a portal to pleasure based sexual and reproductive health around the globe; a qualitative analysis and best practice development study.

Pleasure is often left out of sexual and reproductive health and rights (SRHR) interventions. The expanding evidence base suggests that the inclusion of pleasure can improve SRHR outcomes and increase safer sex practices. However, there is a lack of research into how to include pleasure in applied SRHR work, particularly outside of key groups. This study aims to present the experiences of a cohort of pleasure implementers and develop a series of implementation best practices. Data were gathered from a structured survey filled out by pleasure implementers (n = 8) twice between September 2021 and October 2022 at 6-month intervals. Focus group discussions (FGDs) were carried out remotely with pleasure implementers, those that funded their pleasure work (n = 2) or provided technical support (n = 2) in January 2023. Pleasure implementers, based in Central, East and Southern Africa and India, reported tangible outcomes of their pleasure-based work in various contexts and across diverse groups. Themes that emerged from analysis of the FGDs and survey responses included pleasure as a portal to positive outcomes, barriers to a pleasure approach, and mechanisms by which pleasure allows for open and non-judgmental discussion about sex and pleasure. A series of best practices emerged from pleasure implementer experiences. This study concludes that a pleasure-based approach can be introduced to a wide range of groups and communities, even those assumed too conservative to accept a pleasure approach. The best practices developed offer a range of practically driven recommendations, that others can lean on when integrating a pleasure approach into their work.

Digital support for first time self-injectable contraceptive users in Nairobi, Kenya: A design evaluation.

BACKGROUND: Women in Kenya have an unmet need for contraception, and self-injectable contraceptives offer a new, self-managed fertility control option. Self-injection reduces the need to travel to a facility for ongoing care, but the initial, in-person, consultation may be a barrier. Training in self-injection administration could be delivered via WhatsApp on a mobile phone. METHODS: This study aimed to observe and document the design process of a WhatsApp delivered self-injectable contraceptive service. This design evaluation employs a mixed methods approach using; observation of design meetings, analysis of design documents (process maps, prototypes) and interviews with the design team. Participants who tested the remote training element of the final service design were interviewed about their experiences. RESULTS: Four tasks, delivered by the digital service, were explored in further detail: provide information on self-injectables; ensure the technical and privacy requirements of the video call are met; obtain information from the user to check eligibility; and observe the users first self-injection. The challenges, assumptions, iterations, and learning associated with these key tasks were documented and 3 case studies emerged. These case studies explore how the digital service altered the timing and medium of a clinical interaction, the construction of the user's physical space when interacting with the service and the challenge of performing legitimacy via WhatsApp. CONCLUSION: By examining self-care facilitated by digital technologies, there are opportunities to learn about self-care, digital care and face-to-face care. Through examining the design process, we discovered ways in which digital services can change the rhythm of health care interactions, namely by stretching the time, space and medium of clinical interaction. When interactions are altered in this way, clinical legitimacy must be negotiated in new ways.

Chatbots to Improve Sexual and Reproductive Health: Realist Synthesis.

BACKGROUND: Digital technologies may improve sexual and reproductive health (SRH) across diverse settings. Chatbots are computer programs designed to simulate human conversation, and there is a growing interest in the potential for chatbots to provide responsive and accurate information, counseling, linkages to products and services, or a companion on an SRH journey. OBJECTIVE: This review aimed to identify assumptions about the value of chatbots for SRH and collate the evidence to support them. METHODS: We used a realist approach that starts with an initial program theory and generates causal explanations in the form of context, mechanism, and outcome configurations to test and develop that theory. We generated our program theory, drawing on the expertise of the research team, and then searched the literature to add depth and develop this theory with evidence. RESULTS: The evidence supports our program theory, which suggests that chatbots are a promising intervention for SRH information and service delivery. This is because chatbots offer anonymous and nonjudgmental interactions that encourage disclosure of personal information, provide complex information in a responsive and conversational tone that increases understanding, link to SRH conversations within web-based and offline social networks, provide immediate support or service provision 24/7 by automating some tasks, and provide the potential to develop long-term relationships with users who return over time. However, chatbots may be less valuable where people find any conversation about SRH (even with a chatbot) stigmatizing, for those who lack confidential access to digital devices, where conversations do not feel natural, and where chatbots are developed as stand-alone interventions without reference to service contexts. CONCLUSIONS: Chatbots in SRH could be developed further to automate simple tasks and support service delivery. They should prioritize achieving an authentic conversational tone, which could be developed to facilitate content sharing in social networks, should support long-term relationship building with their users, and should be integrated into wider service networks.

The impact of working alliance in managing youth anxiety and depression: a scoping review.

A working alliance (WA) is a multidimensional construct signifying a collaborative relationship between a client and a therapist. Systematic reviews of therapies to treat depression and anxiety, almost exclusively in adults, show WA is essential across psychotherapies. However, there are critical gaps in our understanding of the importance of WA in low-intensity therapies for young people with depression and anxiety. Here, we describe an initiative to explore the effect of WA on anxiety and depression outcomes in youth aged 14-24 years through a scoping review and stakeholders' consultations (N = 32). We analysed 27 studies; most were done in high-income countries and evaluated one-on-one in-person therapies (18/27). The review shows that optimal WA is associated with improvements in: relationships, self-esteem, positive coping strategies, optimism, treatment adherence, and emotional regulation. Young people with lived experience expressed that: a favourable therapy environment, regular meetings, collaborative goal setting and confidentiality were vital in forming and maintaining a functional WA. For a clinician, setting boundaries, maintaining confidentiality, excellent communication skills, being non-judgmental, and empathy were considered essential for facilitating a functional WA. Overall, a functional WA was recognised as an active ingredient in psychotherapies targeting anxiety and depression in young people aged 14-24. Although more research is needed to understand WA's influence in managing anxiety and depression in young people, we recommend routine evaluation of WA. Furthermore, there is an urgent need to identify strategies that promote WA in psychotherapies to optimise the treatment of anxiety and depression in young people.