"Those are things for married people" exploring parents'/adults' and adolescents' perspectives on contraceptives in Narok and Homa Bay Counties, Kenya.

BACKGROUND: Contraceptive use among adolescent girls is low in many sub-Saharan African countries including Kenya. Attitude and perspectives about contraception of community members including adolescent girls themselves may be likely to limit contraceptive use among adolescent girls. This study was conducted to explore and compare adults'/parents' and adolescent girls' narratives and perspectives about contraception in Narok and Homa Bay counties, Kenya. METHODS: Qualitative data from 45 in-depth-interviews conducted with purposively selected consenting adolescent girls aged 15-19 was used. Additionally, twelve focus group discussions were held with 86 consenting adults conveniently recruited from the two counties. All discussions were conducted in the local language and audio recorded following consent of the study participants. Female moderators were engaged throughout the study making it appropriate for the study to solicit feedback from the targeted respondents. RESULTS: Findings highlighted adults' perceptions on adolescents' sexuality and the presence of stringent conceptions about the side-effects of contraception in the study communities. Some participants underscored the need for open contraceptive talk between parents and their adolescent girls. Four main themes emerged from the discussions; (i) Perceptions about adolescents' sexuality and risk prevention, (ii) Conceptions about contraception among nulligravida adolescents: fear of infertility, malformation and sexual libertinism, (iii) Post-pregnancy contraceptive considerations and (iv) Thinking differently: divergent views regarding contraceptives and parent/adolescent discussion. CONCLUSIONS: Our findings suggest the need for increased attention towards adolescents and their caregivers particularly in demystifying contraceptive misconceptions. Programmatic responses and models which include the provision of comprehensive sexuality education and increased access to and utilization of SRH information, products and services through a well-informed approach need to be well executed. Programmatic efforts like SRH community education should further seek to enhance the capacity of parents to discuss sexuality with their adolescents.

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

BACKGROUND: Myths 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. METHODS: We 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. RESULTS: Results 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. CONCLUSIONS: This 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.

HIV comprehensive knowledge and prevalence among young adolescents in Nigeria: evidence from Akwa Ibom AIDS indicator survey, 2017.

BACKGROUND: Despite the recent increase in HIV infections among adolescents, little is known about their HIV knowledge and perceptions. This study, therefore, sought to examine the factors associated with comprehensive HIV knowledge, stigma, and HIV risk perceptions among young adolescents aged 10-14 years in Akwa Ibom State, Nigeria. Additionally, consenting parents and assenting young adolescents were tested for HIV. METHODS: We used cross-sectional data from the 2017 Akwa Ibom AIDS Indicator Survey to analyze comprehensive HIV knowledge, stigma, and HIV risk perceptions among young adolescents. Demographic characteristics of young adolescents were summarized using descriptive statistics. Chi-square test (or Fisher's exact test in cases of small subgroup sample sizes) was used to elicit associations between demographics and study outcomes. Separate multivariable logistic regression models were then conducted to determine associations with the study outcomes. Sampling weights were calculated in order to adjust for the sample design. P-values less than 0.05 were considered to be significant. RESULTS: A total of 1818 young adolescents were interviewed. The survey highlighted significant low levels of comprehensive HIV knowledge (9.4%) among young adolescents. Adolescent-parent discussions [AOR = 2.19, 95% C.I (1.10-4.38), p = 0.03], schools as sources of HIV information [AOR = 8.06, 95% C.I (1.70-38.33), p < 0.001], and sexual activeness [AOR = 2.55, 95% C.I (1.16-5.60), p = 0.02] were associated with comprehensive HIV knowledge. Majority (93%) of young adolescents perceived themselves not to be at risk of HIV. Overall, 81.5% of young adolescents reported stigmatizing tendencies towards people living with HIV. HIV prevalence among young adolescents was 0.6%. CONCLUSIONS: Results indicate low comprehensive HIV knowledge among young adolescents. Our findings suggest that there is a need for increased attention towards young adolescents particularly in the provision of comprehensive, functional sexuality education, including HIV at the family- and school-levels. Consequently, age appropriate interventions are needed to address the epidemiological risks of young adolescents that are influenced by a myriad of social issues.

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.

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.

BACKGROUND: Young people face special challenges to accessing needed sexual and reproductive health (SRH) information and support. With high penetration and access, mobile phones provide a new channel for reaching young people, but there is little evidence around the impact of digital interventions on improving health outcomes. The Adolescent/Youth Reproductive Mobile Access and Delivery Initiative for Love and Life Outcomes (ARMADILLO) study will assess the effect of an intervention providing SRH information to young people via text message on their mobile phones in Kenya and Peru. This protocol details an open, individually-randomized, three-arm trial lasting seven weeks to assess the effect of the ARMADILLO intervention on dispelling myths and misconceptions related to contraception. A secondary objective is to determine whether youth given access to SRH information via text message can accurately retain that information. METHODS: Following a household enumeration, one eligible youth per household will be randomly selected for participation and randomized by computer into one of the three arms. Intervention arm participants will receive access to ARMADILLO content, control participants will receive no information, and 'Arm 3' participant interactions will vary by site: in Kenya, they will be alerted to various SRH domains and encouraged to learn on their own; in Peru, they will receive key content from each domain with the option to learn more if they wish. Participants will complete multiple-choice questionnaires administered by data collectors at baseline (prior to randomization), at intervention-period end (after week seven), and eight weeks after timing out of the intervention period. DISCUSSION: Part of the Sustainable Development Goal commitment towards ensuring healthy lives and promoting well-being for all at all ages includes a commitment to 'ensuring universal access to sexual health and reproductive health-care services, including for family planning, information and education'. If proven to be effective, interventions like ARMADILLO can bridge an important gap towards achieving universal access to SRH information and education for an otherwise difficult-to-reach group. TRIAL REGISTRATION: This trial was retrospectively registered with the ISRCTN Registry and assigned registration number ISRCTN85156148 on 29 May, 2018.

Are respectful maternity care (RMC) interventions effective in reducing intrapartum mistreatment against adolescents? A systematic review.

Intrapartum mistreatment of women by health professionals is a widespread global public health challenge. It leads to a decreased quality of maternity care and is evinced to precipitate detrimental maternal and neonatal outcomes, especially among adolescents. Relatedly, research indicates that Respectful Maternity Care (RMC) interventions are especially effective in mitigating intrapartum mistreatment and improving birth outcomes. However, evidence on the success of RMC, specifically for adolescents, is insufficient and unaggregated. Accordingly, this review specifically aims to synthesize existing evidence on RMC care provision to adolescent parturients. This review searched for relevant literature from published and gray sources including PubMed, ScienceDirect, Cochrane, CINAHL, PsycINFO, Scopus, as well as Population Council, WHO and White Ribbon Alliance data sources published between January 1990 and December 2021. Based on eligibility, studies were selected and quality appraised after which thematic analysis and narrative synthesis was conducted. Twenty-nine studies were included in the systematic review. Due to paucity and heterogeneity of quantitative studies, the review was limited to a thematic analysis. Adolescent and health provider perspectives alike underscored the burden and outcomes of mistreatment. Need for RMC interventions to improve quality of maternity care was recommended by majority of studies. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020183440.

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, <5% of participants did not have any formal education, <10% were living alone, about 50% were single and >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. TRIAL REGISTRATION NUMBER: ISRCTN85156148.

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. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020183440.

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).

BACKGROUND: 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. OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. CLINICAL TRIAL: International Standard Randomized Controlled Trial Number (ISRCTN): 85156148; http://www.isrctn. com/ISRCTN85156148.