Design and impact evaluation of a digital reproductive health program in Rwanda using a cluster randomized design: study protocol.

BACKGROUND: Rwandan 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. METHODS: The 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. DISCUSSION: This 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 REGISTRATION: ClinicalTrials.gov Identifier: NCT04198272 . Prospectively registered 13 December 2019.

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.