A multi-media digital intervention to improve the sexual and reproductive health of female adolescent emergency department patients

A Digital Sexual Health Intervention for Urban Adolescent and Young Adult Male Emergency Department Patients: User-Centered Design Approach

BACKGROUND

Adolescents and young adults frequently present to the emergency department (ED) for medical care and continue to have many unmet sexual health needs. Digital interventions show promise to improve adolescent and young adult sexual health; yet, few interventions focus on male ED patients, despite their infrequent use of contraceptives and rising rates of sexually transmitted infections.

OBJECTIVE

This paper describes the design and development of Dr. Eric (Emergency Room Interventions to Improve Care), a digital app focused on promoting condom use among sexually active adolescent and young adult male ED patients.

METHODS

This study followed 4 phases of app development, which were based on user-centered design and the software development lifecycle. In phase 1, define, we explored our target population and target health problem (infrequent condom use among male ED patients) by collecting key stakeholder input and conducting in-depth interviews with male patients and urban ED medical providers. In phase 2, discover, we partnered with a digital product agency to explore user experience and digital strategy. In phase 3, design, we refined Dr. Eric's content, a 5-part sexual health educational module and a 10-week SMS text messaging program that focuses on condom use and partner communication about effective contraceptives. We conducted semistructured interviews with male adolescent and young adults to gather feedback on the app and perform usability testing, editing the app after each interview. We also interviewed informatics experts to assess the usability of a high-fidelity prototype. Interviews were recorded and analyzed via descriptive thematic analysis; informatic expert feedback was categorized by Nielsen's heuristic principles. In phase 4, develop, we created the technical architecture and built a responsive web app. These findings were gathered leading to the final version of the digital Dr. Eric program.

RESULTS

Using data and key stakeholder input from phases 1 and 2, we iteratively created the Dr. Eric prototype for implementation in the ED setting. Interviews with 8 adolescent and young adult male ED patients suggested that users preferred (1) straightforward information, (2) a clear vision of the purpose of Dr. Eric, (3) open-ended opportunities to explore family planning goals, (4) detailed birth control method information, and (5) games presenting novel information with rewards. Five usability experts provided heuristic feedback aiming to improve the ease of use of the app. These findings led to the final version of Dr. Eric.

CONCLUSIONS

Following these mobile health development phases, we created a digital sexual health mobile health intervention incorporating the principles of user experience and interface design. Dr. Eric needs further evaluation to assess its efficacy in increasing condom use among adolescent and young adult male ED patients. Researchers can use this framework to form future digital health ED-based digital interventions.

Well-informed or misinformed? News-Finds-Me perception in shaping sexual and reproductive health knowledge and behavioral intentions among Chinese women

The News-Finds-Me (NFM) perception reflects individuals' belief of being well-informed even without actively seeking out news on social media. Despite studies examining the NFM perception in political and COVID-19 contexts, its implications in specific health contexts and the underlying mechanisms toward behavioral outcomes remain largely unexplored. Through a nationwide online survey of Chinese women residing in both rural and urban areas, this study revealed a positive association between the NFM perception and sexual and reproductive health (SRH) misperceptions, as well as an overassessment of factual knowledge. Furthermore, this study identified the mediating roles of knowledge miscalibration and SRH misperceptions linking the NFM perception to SRH behavioral intention. Notably, the relationship between the NFM perception and knowledge miscalibration was contingent upon individual differences in optimism regarding personal risks related to SRH diseases. The findings of this study not only extend the negative implications of the NFM perception in the SRH context and behavioral outcomes but also provide practical guidelines for promoting effective health learning in the contemporary algorithm-driven information environment.

Contraception Initiation in the Emergency Department: Adolescent Perspectives

PURPOSE

The purpose of this study was to identify factors affecting contraceptive intention and behavior among adolescent females in the pediatric Emergency Department.

METHODS

We conducted a qualitative interview study nested within a larger prospective cohort study examining adolescent contraceptive counseling for females ages 15-18 years at-risk of unintended pregnancy presenting to the pediatric Emergency Department. Interviews were conducted in a subset of participants. The ecologically expanded Theory of Planned Behavior, expert opinion, and literature review informed the interview guide. Interviews were recorded, transcribed, coded and monitored for thematic saturation.

RESULTS

Twenty-eight interviews were analyzed. Mean age was 17.1 years. Themes were mapped to ecologically expanded Theory of Planned Behavior constructs. Within health system influences, prior contraceptive experiences and patient-clinician interactions were described. Within community influences, contraceptive education, knowledge and misinformation, teen pregnancy norms, and social media impacts were described. Within attitudes influences, side-effect and safety concerns, contraceptive motivations and teen pregnancy beliefs were described. Within subjective norm influences, peer and family impacts were described. Within perceived behavioral control, Emergency Department (ED) counseling intervention impacts were described.

DISCUSSION

We identified factors affecting contraceptive initiation/behavior among an ED adolescent population that otherwise may not have received contraceptive education in similar detail as provided by study clinicians. Adolescents' prior contraceptive and clinician interactions, limited access to contraceptive education, knowledge and misinformation, and side-effect and safety concerns affected initiation. Peer/family sharing and social media were leading contraceptive information sources. Future studies should incorporate insights into adolescent ED intervention design to make optimal use of resources while maximizing potential benefit.

The evolving role of emergency medicine in family planning services

PURPOSE OF REVIEW

The emergency department serves as an essential access point for a variety of healthcare services. This review will examine the recent expansion of family planning and reproductive health services in the emergency department.

RECENT FINDINGS

An increasing number of patients present to emergency departments for early pregnancy loss (EPL), abortion care, and contraceptive management. Availability of comprehensive EPL management varies dramatically, possibly due to lack of provider knowledge or training. Particularly in remote settings, educational interventions - such as providing information about medication management and training in uterine aspiration - may standardize this management. Restrictive abortion laws raise concerns for changing and increased patient presentations to the emergency department for complications related to unsafe or self-managed abortion. Emergency medicine providers should anticipate that more patients will present without a prior ultrasound confirming intrauterine pregnancy prior to initiating no-touch or self-managed abortions. Particularly among pediatric patients, there may be a role for contraceptive counseling during an emergency department visit. Novel strategies, including web-based interventions and emergency department-based curricula for contraceptive counseling, may help reach those who otherwise may not seek reproductive healthcare in a clinic setting.

SUMMARY

The intersection of emergency medicine and reproductive healthcare is a promising frontier for providing immediate, patient-centered, family planning care. Continued research and provider education are necessary to refine these approaches, address disparities, and respond to the changing reproductive healthcare landscape.

Expanding Contraceptive Access for Teens-Leveraging the Pediatric Emergency Department

PURPOSE

Adolescents have limited access to sexual healthcare services, and the emergency department (ED) may be the only place some will seek care. We implemented an ED-based contraception counseling intervention to assess intervention feasibility, and adolescent intention to initiate contraception, contraception initiation, and follow-up visit completion.

METHODS

This prospective cohort study trained advanced practice providers in the EDs of two pediatric urban academic medical centers to deliver brief contraception counseling. A convenience sample of patients enrolled from 2019 to 2021 included females aged 15-18 not pregnant/desiring pregnancy and/or using hormonal contraception/an intrauterine device. Participants completed surveys to assess demographics and intention to initiate contraception (yes/no). Sessions were audiotaped and reviewed for fidelity. We ascertained contraception initiation and follow-up visit completion via medical record review and participant survey at 8 weeks.

RESULTS

Twenty-seven advanced practice providers were trained, and 96 adolescents were counseled/responded to surveys (mean age 16.7 years; 19% non-Hispanic White, 56% non-Hispanic Black; 18% Hispanic). Mean counseling duration was 12 minutes and >90% of reviewed sessions maintained fidelity to content/style. Most participants (61%) reported intention to initiate contraception, and these participants were older and more likely to report prior contraceptive use, compared to those without intention. One-third (33%) initiated contraception in the ED or after the follow-up visit.

DISCUSSION

Contraceptive counseling was feasible to integrate in the ED visit. Intention to initiate contraception was common and many adolescents initiated contraception. Future work should increase the pool of trained providers and supports for same-day contraception initiation for those desiring in this novel setting.

Feasibility of a Contraception Intervention for Hospitalized Adolescents and Young Adults

OBJECTIVES

Unintended pregnancy in adolescents and young adults (AYAs) is linked with negative outcomes. We sought to evaluate the feasibility, acceptability, and preliminary efficacy of a contraception intervention in the pediatric hospital.

METHODS

We conducted a pilot study of hospitalized AYA females aged 14 to 21 years who reported past or anticipated sexual activity. A health educator offered a tablet-based intervention to provide contraception education and medications, if desired. We assessed feasibility (ie, intervention completion, duration, disruption to care), acceptability (ie, proportion rating as acceptable or satisfactory) among AYAs, parents or guardians, and healthcare providers, as well as preliminary efficacy (eg, contraception uptake) at enrollment and 3-month follow up.

RESULTS

We enrolled 25 AYA participants; mean age was 16.4 ± 1.5 years. The intervention demonstrated high feasibility as all enrolled participants (n = 25, 100%) completed the intervention and median intervention duration was 32 (interquartile range 25-45) minutes. Among 11 nurses, 82% (n = 9) reported the intervention was not at all or minimally disruptive to their workflow. All AYAs were very or somewhat satisfied with the intervention and 88% (n = 7) of 8 parents and guardians surveyed felt it was acceptable for the educator to meet privately with their child. Eleven participants (44%) started hormonal contraception, most commonly the subdermal implant (n = 7, 64%), and 23 (92%) received condoms.

CONCLUSIONS

Our findings support the feasibility and acceptability of our contraception intervention in the pediatric hospital resulting in contraception uptake among AYAs. Efforts to expand access to contraception are important to reduce unintended pregnancy, especially as restrictions to abortion are increasing in some states.

A human-centered designed outreach strategy for a youth contraception navigator program

OBJECTIVE

To identify key elements of an outreach strategy for a youth contraception navigator program designed to help young people overcome barriers to contraception access.

METHODS

A human-centered design approach was used to engage adolescents aged 15-17 in co-design sessions. Human-centered design techniques, such as affinity diagramming and model building were used to inform key elements of the communication model and the final outreach strategy messages.

RESULTS

Messages focused on the individual, normalizing talking about birth control, acknowledging the challenges to obtaining birth control, explaining how the navigator program works resonate with young people. Having images of diverse participants, offering information about birth control, and showing images of reputable sources will enhance trust.

CONCLUSIONS

A name (IN Control) and key elements of an outreach strategy were determined for the navigator program. It is important to work with key stakeholders and co-design the optimal strategy and messages to assure that the intended audience is reached, and the desired behavior change is achieved.

INNOVATION

Human-centered design techniques can be used to provide insight into programmatic outreach strategies for a contraception navigator program to increase their impact and ultimate success.

Designing illustrative social media stories to promote adolescent peer support and healthy sexual behaviors

Objective

Adolescent females in the United States continue to have unmet sexual and reproductive healthcare needs. Research shows that interventions incorporating peer support can augment perceived self-efficacy and reinforce healthy behaviors. Yet, few user-centered digital sexual health interventions incorporate peer support, and aim to change perceptions of peer norms and model social skills. The objective of this study was to design and demonstrate the receptivity of adolescent females to illustrated digital social media stories that promote healthy sexual behaviors and peer social support.

Methods

We conducted a three-phase study approved by our Institutional Review Board. In Phase 1, we presented sexually active adolescent female emergency department patients aged 14-19 with eight sexual health scenarios via a survey study. Participants wrote three text messages addressed to the protagonist of each scenario which motivated and encouraged her to consider the use of contraceptives. Messages were scored based on the construct of peer support (emotional, tangible, informational, and belonging). In Phase 2, we worked with a professional artist and screenwriter to design digital sexual health comics using the gathered messages. In Phase 3, we gathered feedback on the comics from adolescent female emergency department patients.

Results

Females (n  =  22) provided 352 messages. Using top rated messages, we designed five digital visualizations in a running story called Mari tells it like it is. Each story incorporated 5-12 peer-authored quotes. We inserted the final images into Instagram®. Additional females (n  =  39) found the images "relatable," "super-realistic," and "educational."

Conclusion

Collecting peer-authored texts from our local adolescent community led to the creation of well-received sexual health visualizations. This novel method of design incorporated adolescent voices to promote peer support and healthy behaviors.

Use of Digital Health Interventions in Sub-Saharan Africa for Health Systems Strengthening Over the Last 10 Years: A Scoping Review Protocol

Background

Digital Health Interventions (DHIs) refers to the utilization of digital and mobile technology to support the health system in service delivery. Over the recent years, advanced computing, genomics, and artificial intelligence are considered part of digital health. In the context of the World Health Organization (WHO) global strategy 2020-2025, digital health is defined as "the field of knowledge and practice associated with the development and use of digital technologies to improve health." The scoping review protocol details the procedure for developing a comprehensive list of DHIs in Sub-Saharan Africa and documenting their roles in strengthening health systems.

Method and Analysis

A scoping review will be done according to the Joanne Briggs institute reviewers manual and following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist and explanation. The protocol has been registered at the Open Science Framework (OSF) database at https://osf.io/5kzq7. The review will include DHIs conceptualized/developed/designed, adapted, piloted, deployed, scaled up, and addressing health challenges in Sub-Saharan Africa. We will retrieve data from the global DHI repository-the WHO Digital Health Atlas (DHA)- and supplement it with information from the WHO eHealth Observatory, eHealth Survey (2015), and eHealth country profiles report. Additional searches will be conducted in four (4) electronic databases: PubMed, HINARI-Reasearch4Life, Cochrane Library, and Google Scholar. The review will also include gray literature and reference lists of selected studies. Data will be organized in conceptual categories looking at digital health interventions' distinct function toward achieving health sector objectives.

Discussion

Sub-Saharan Africa is an emerging powerhouse in DHI innovations with rapid expansion and evolvement. The enthusiasm for digital health has experienced challenges including an escalation of short-lived digital health interventions, duplication, and minimal documentation of evidence on their impact on the health system. Efficient use of resources is important when striving toward the use digital health interventions in health systems strengthening. This can be achieved through documenting successes and lessons learnt over time.

Conclusion

The review will provide the evidence to guide further investments in DHIs, avoid duplication, circumvent barriers, focus on gaps, and scale-up successful interventions.