The ARMADILLO text message intervention to improve the sexual and reproductive health knowledge of adolescents in Peru: Results of a randomized controlled trial.

BACKGROUND: The ARMADILLO Study determined whether adolescents able to access SRH information on-demand via SMS were better able to reject contraception-related myths and misconceptions as compared with adolescents receiving pushed SMS or no intervention. TRIAL DESIGN: This trial was an unblinded, three-arm, parallel-group, individual RCT with a 1:1:1 allocation. Trial registration: ISRCTN85156148. METHODS: This study was conducted in Lima, Peru among participants ages 13-17 years. Eligible participants were randomized into one of three arms: Arm 1: access to ARMADILLO's SMS information on-demand; Arm 2 access to ARMADILLO SMS information pushed to their phone; Arm 3 control (no SMS). The intervention period lasted seven weeks. At baseline, endline, and follow-up (eight weeks following endline), participants were assessed on a variety of contraception-related myths and misconceptions. An index of myths-believed was generated. The primary outcome assessed the subject-specific change in the mean score between baseline and endline. Knowledge retention from endline to follow-up was also assessed, as was a 'content exposure' outcome, which assessed change in participants' knowledge based on relevant SMS received. RESULTS: In total, 712 participants were randomized to the three arms: 659 completed an endline assessment and were included in the primary analysis. Arm 2 participants believed fewer myths at endline compared with control arm participants (estimated subject-specific mean difference of -3.69% [-6.17%, -1.21%], p = 0.004). There was no significant difference between participants in Arm 1 vs. the control Arm, or between participants in Arm 1 vs. Arm 2. A further decrease in myths believed between endline and follow-up (knowledge retention) was observed in all arms; however, there was no difference between arms. The content exposure analysis saw significant reductions in myths believed for Arm 1 (estimated subject-specific mean difference of -9.47% [-14.83%, -4.11%], p = .001) and Arm 2 (-5.93% [-8.57%, -3.29%], p < .001) as compared with the control arm; however Arm 1's reduced sample size (n = 28) is a severe limitation. DISCUSSION: The ARMADILLO SMS content has a significant (but small) effect on participants' contraception-related knowledge. Standalone, adolescent SRH digital health interventions may affect only modest change. Instead, digital is probably best used a complementary channel to expand the reach of existing validated SRH information and service programs.

Developing an SMS text message intervention on sexual and reproductive health with adolescents and youth in Peru.

BACKGROUND: Improved access to sexual and reproductive health (SRH) services and information is essential for supporting adolescents and youth in making informed decisions and optimizing each young person's outcomes related to their SRH, health and well-being and countries' current and future social and economic development. Mobile phones offer opportunities for young people to privately access SRH content and to be linked to SRH services. The objective of this study was to develop the content for an SMS (short message service or "text message") platform jointly with adolescents and youth in three regions in Peru (Lima, Ayacucho and Loreto) as part of the ARMADILLO (Adolescent/Youth Reproductive Mobile Access and Delivery Initiative for Love and Life Outcomes) Study. METHODS: Content development was done in three stages. During Stage 1, we held community consultations with 13-17 year old adolescents, 18-24 year old youth and professionals who work with young people through the education and health sectors ("adult advisers") to identify and rate SRH topics of interest through group free- and guided-brainstorming activities and an individual written sharing activity. During Stage 2, the team developed the preliminary domains, sub-domains and content for the SMS platform. During Stage 3, we held focus groups with adolescents to validate the SMS content, including both individual scoring of and group feedback for each SMS. Group feedback asked about their general impressions and understanding and their thoughts about the language and usefulness of the SMS. RESULTS: A total of 172 adolescents and youth ages 13-24 and 20 adult advisers participated. Adolescents and youth brainstormed and rated SRH topics and sub-topics that led to the initial structure for the SMS platform, with 9 domains, 25 sub-domains and 146 draft SMS. Adolescents provided high scores for the SMS, with all sub-domains receiving average scores of 3.0 or higher (out of 4.0) for the SMS included. Adolescents also provided suggestions to optimize content, including improvements to unclear messages, resulting in SMS with adolescent-friendly content in simple, straightforward language. This process also revealed that adolescents lacked knowledge and had misconceptions related to contraceptive methods. CONCLUSION: This study details the systematic process used to develop relevant and accessible SRH information through a participatory approach. We document critical information about what young people know and how they think, enabling us to understand their perspective and literally speak their language. Results also provide future directions for programmatic, research and policy efforts with young people, in particular around gender norms, interpersonal violence, and access to SRH information and services, in similar settings.

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.

Lessons learnt from the CERCA Project, a multicomponent intervention to promote adolescent sexual and reproductive health in three Latin America countries: a qualitative post-hoc evaluation.

The Community-Embedded Reproductive Health Care for Adolescents (CERCA) Project was implemented in Bolivia, Ecuador and Nicaragua (2011-2014) to test the effectiveness of interventions preventing teenage pregnancies. As the outcome evaluation showed limited impact, a post-hoc process evaluation was carried out to determine if and how CERCA's design, implementation, monitoring and evaluation affected the results. We did a document analysis and conducted 18 in-depth interviews and 21 focus group discussions with stakeholders and beneficiaries. Transcripts were analyzed using directed content analysis. Data showed that CERCA sensitized stakeholders and encouraged the discussion on this sensitive issue. In terms of design, a strong point was the participatory approach; a weak point was that the detailed situation analysis was completed too late. In terms of implementation, a strong point was that multifaceted activities were implemented; a weak point was that the activities were not pilot tested for feasibility/acceptability and evolved substantially throughout the Project. In terms of monitoring, strong points were that regular monitoring kept the Project on track administratively/financially; a weak point was that monitoring indicators did not change as the intervention package changed. In terms of evaluation, weak points were the substantial attrition rate and narrow focus on adolescents. This study provides recommendations for future projects.

Family and peer support matter for precoital and coital behaviors among adolescents in Lima.

We analyzed the association between sub-scales developed with adolescents and the outcomes of precoital behaviors and vaginal sex in Lima, Peru. Adolescent participants in key informant sessions operationalized concepts identified during qualitative concept mapping into several sub-scales. Face and content validity testing and pilot application with respondent debriefing were used to refine the sub-scales. Three hundred 15-17 year olds were surveyed about the sub-scales, socio-demographics and sexual behaviors. Exploratory factor analysis confirmed six sub-scales, self-image, goals and decision-making, family education, parental rules/control, school support and peer support, which we regressed on the outcomes. Twice as many males as females reported more than three precoital behaviors and vaginal sex. Higher peer support reduced the likelihood of vaginal sex and precoital behaviors and higher family education reduced precoital behaviors. Results affirm the importance of including adolescents in the entire research process and of sex education with family- and peer-based strategies.

Constrained choices: adolescents speak on sexuality in Peru.

While numerous studies have explored young people's sexual behaviour in Peru, to date few have explored how adolescents situate sexuality within the context of their broader lives. This information is needed to inform policies and programmes. Life history interviews were conducted with 20 12-17-year-old young women and men from a low-income settlement near Lima, Peru. Data were analysed using holistic content analysis and grounded theory. Sexuality had a strong presence in respondents' lives. However, interviewees viewed the full expression of their sexuality as a constrained choice. Particular constraints derive from the belief that sexual intercourse always results in pregnancy; the nature of sex education; the provision of proscriptive advice; and the family tensions, economic problems, racism and violence present in young people's lives. The results of this study can inform policies and programmes to support young people as they make sexuality-related decisions.

Adolescents can know best: using concept mapping to identify factors and pathways driving adolescent sexuality in Lima, Peru.

The primary objective of this study was to identify and describe individual- and environmental-level factors that Peruvian adolescents perceive to be related to adolescent sexuality. A series of concept mapping sessions were carried out from January-March 2006 with 63 15-17 year olds from a low-income community near Lima in order for adolescents to: (1) brainstorm items that they thought were related to sexuality, (2) sort, group and rate items to score their importance for sexuality-related outcomes, and (3) create pathways from the groups of items to engaging in sex. Brainstorming resulted in 61 items, which participants grouped into 11 clusters. The highest rated clusters were personal values, respect and confidence in partner relationships, future achievements and parent-child communication. The pathway of decision-making about having sex primarily contained items rated as only moderately important. This study identified important understudied factors, new perspectives on previously-recognized factors, and possible pathways to sexual behavior. These interesting and provocative findings underscore the importance of directly integrating adolescent voices into future sexual and reproductive health research, policies and programs that target this population.

What is adolescence?: Adolescents narrate their lives in Lima, Peru.

This study explores the lives of Peruvian adolescents in a low-income human settlement outside of Lima. Twenty 12-17 year olds were asked to narrate their own life stories using the life history narrative research method. Holistic content analysis was coupled with a grounded-theory approach to explore these data. Intergenerational responsibility, family tensions, economic pressures, racism and violence emerged without prompting and dominated the narrators' life stories, underscoring the degree to which these adolescents lack access to the supportive individuals and structures that are key to positive adolescent development. The challenges faced by these and the other 5.8 million 10-19 year olds in Peru require increased attention to the role of families, peers and communities in ensuring that adolescents are able to maintain their well-being and achieve their future expectations.