Abstract
BackgroundRwandan adolescents have limited access to high-quality family planning and reproductive health (FP/RH) information and care to prevent unplanned pregnancy and HIV/STIs. In addition to the immediate implications for health and well-being, teenage pregnancy is a significant cause of school drop-out, limiting girls’ future potential and employment opportunities. This study introduces a direct-to-consumer digital education program that uses storytelling to deliver age-appropriate FP/RH information and economic empowerment training to adolescents. It also facilitates access to high-quality, youth-friendly FP/RH care and products. We evaluate two different school-based models of its implementation to understand how to optimize the uptake of contraception and HIV testing among adolescents.MethodsThe study consists of two distinct phases. The first formative intervention design phase, conducted from 2016 to 2019, used a human-centered design methodology to develop the intervention alongside over 600 Rwandan adolescents, their parents, teachers, and healthcare providers. Through this methodology, we sought to maximize the fit between evidence-based practices (uptake of modern contraception and HIV testing) and the implementation context of adolescents in Rwanda. The second phase is an impact evaluation, in which we will use a Hybrid Trial Type 2 Effectiveness-Implementation study design to determine the overall effectiveness of this digital intervention as well as the relative effectiveness of the two different school-based implementation models. This takes the form of a 3-arm cluster-randomized non-inferiority trial, with a sample of 6000 youth aged 12–19 in 60 schools across 8 districts in Rwanda. Primary outcome measures include use of modern contraception, delayed initiation of childbearing, and uptake of HIV testing.DiscussionThis study will yield insights into not only whether this digital intervention is successful in achieving the intended sexual and reproductive health outcomes, but also which mechanisms are likely to drive this effectiveness. The methodologies used are broadly applicable to the design, implementation, and evaluation of other behavior-based health programs in low and middle-income countries.Trial registrationClinicalTrials.gov Identifier: NCT04198272. Prospectively registered 13 December 2019.
Highlights
Rwandan adolescents have limited access to high-quality family planning and reproductive health (FP/RH) information and care to prevent unplanned pregnancy and Human Immunodeficiency Virus (HIV)/Sexually Transmitted Infection (STI)
The structure and content of the native app is the same as the web app, so we have focused our discussion on the web app for simplicity. 3In addition to a school implementation model, CyberRwanda is being delivered in one Youth Center in each study district in order to meet the needs of out-of-school youth
While young people are able to obtain some products for free or lower cost at health facilities, our research found that young people prefer to go to pharmacies to purchase products
Summary
The study consists of two distinct phases. The first phase, conducted from 2016 to 2019, is the intervention design phase in which we used a human-centered design methodology consisting of small group discussions, structured interviews, and rapid prototyping of intervention elements with over 600 adolescents and other stakeholders to determine the most effective and appropriate design for the intervention. Given the cultural and social sensitivity of topics concerning contraception and adolescent reproductive health, a key area of investigation in initial design research was how these messages would be received, and how to frame the intervention in a socially acceptable and constructive manner. During this phase, we talked to a wide range of parents, teachers and community leaders, including some religious leaders, to get their input on the concept and some early prototypes.
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