An mHealth Intervention for Pregnancy Prevention for LGB Teens: An RCT

Sexual Health Advocacy for Guys (SHAG): a randomized trial of the impact of a text-messaging program on HIV incidence and STI testing among a national sample of sexual minority cisgender adolescent and young adult men

BACKGROUND

Disparities in sexually transmitted infections (STI) including human immunodeficiency virus (HIV) among sexual minority boys and young men are substantial. Effective HIV and STI prevention programs that include access to pre-exposure prophylaxis (PrEP) medication do not consistently include younger sexual minority men. Text-messaging programs for HIV prevention have been associated with increases in HIV testing among sexual minority adolescent boys, but these programs have not incorporated a focus on PrEP or STIs beyond HIV.

METHODS

We will conduct a two-arm randomized trial with 1:1 allocation comparing the superiority of text messaging-based intervention focused on HIV and STI prevention to a generic HIV education program with content focused on promoting a "healthy lifestyle" (e.g., self-esteem). Outcomes include testing for HIV and other STIs, increasing PrEP and PEP use, and HIV incidence. Generalized linear models will be used to estimate treatment effects on primary study outcomes, with longitudinal models (estimated based on Generalized Estimating Equations) specified to examine effects over time. Mediation will be assessed based on a product of coefficients approach with bootstrapped standard errors.

DISCUSSION

This is the first randomized controlled trial (RCT) with a national sample of cisgender sexual minority adolescent boys and young men 13-22 years of age exploring the efficacy of a text messaging-based intervention in increasing HIV and STI testing, and PReP and PEP use. Findings will inform the scalability of text messaging programs for sexual health promotion and at-home STI testing, and will demonstrate impacts of a behavioral health intervention on HIV incidence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06230367 . Date of registration: 1/29/2024.

Recruiting sexual minority youth for a drug abuse prevention trial: Comparing Instagram and Facebook

BACKGROUND

Despite youth's shift from Facebook to Instagram, the literature on how to use Instagram to recruit youth for clinical trials is scant. This paper reports procedures and comparative metrics on the use of Facebook and Instagram to recruit a nationwide sample (N = 1216) of LGBQ youth, aged 15 and 16 years, for an online drug abuse prevention trial.

METHODS

Our recruitment campaign used ads on Facebook and promoted posts on Instagram. Ads and posts shared common images, headlines, and captions. Ads and posts directed youth to a study recruitment website for informed consent and enrollment procedures.

RESULTS

Our campaign ran for 48 non-consecutive days, yielded N = 1216 participants, had a total cost of $25,400.31, and an average cost per participant of $20.89. Facebook ads and Instagram promoted posts ran for a similar number of days. However, compared to Instagram, Facebook ads cost more than twice as much (115 %), had 51 % fewer clicks, and had an average cost-per-click that was 338 % higher. Furthermore, despite being shown to users more than 4 times as often and garnering more than twice as many unique views, Facebook ads had a click-through-rate that was 90 % lower than Instagram promoted posts.

CONCLUSION

Instagram promoted posts outperformed ads on Facebook by driving more potential participants to the study recruitment website and for less money.

Screening and Retaining Adolescents Recruited Through Social Media: Secondary Analysis from a Longitudinal Clinical Trial

BACKGROUND

Social media has become a popular method to recruit participants, particularly for studies with hard-to-reach populations. These studies still face challenges in data quality and, for longitudinal studies, sample retention. However, in addition to aiding in recruitment, social media platforms can help researchers with participant verification and tracking procedures during the study. There is limited previous research describing how longitudinal studies can use social media to screen and retain participants.

OBJECTIVE

This paper describes strategies implemented to screen and retain a nationwide sample of sexual minority youth who were recruited through social media platforms for a longitudinal study testing a drug abuse prevention program.

METHODS

Our screening strategies for participants included collecting necessary demographic information (name, phone, email, and social media accounts), verifying this information using publicly available web-based records, and sending confirmation emails to ensure working email addresses and correct dates of birth. Retention strategies included communications designed to develop positive participant relationships, incentives for survey completion, regular updating of participant contact information, targeting hard-to-reach participants, and using social media as an alternative means of contacting participants.

RESULTS

During enrollment, although the only demographic data required were a phone number and an email address, 87.58% (1065/1216) of participants provided their Instagram as an alternative means of contact. This form of alternative communication remains the most preferred with 87.40% (1047/1198) of participants continuing to provide an Instagram username as of January 2023, about 3 years after recruitment began. In comparison, other alternative means of contact (eg, Facebook and alternative email) were provided by only 6.43% (77/1198) to 56.18% (673/1198) of participants. Direct messaging on Instagram was used to successfully confirm participant identity, remind participants to take annual follow-up surveys, and update lost participant contact information. Screening and retention strategies used in the study have helped achieve 96.30% (1171/1216) to 96.79% (1177/1216) sample retention across 3 waves of data collection.

CONCLUSIONS

Though social media can be a helpful tool to recruit participants, attrition and participant authenticity difficulties may be associated with this method. Screening and retention strategies can be implemented to improve retention. Internet searches are effective for screening youth to ensure they meet eligibility requirements. Additionally, social media-Instagram in this study-can help to track and locate participants who do not respond to traditional contact methods.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03954535; https://clinicaltrials.gov/study/NCT03954535.

Balancing career goals and parenthood desires: results from a survey of undergraduate pre-health students at a hispanic-serving institution in Texas

OBJECTIVE

To examine family planning and fertility experiences and views, as well as desired parenthood timing and career plans, of diverse undergraduate pre-health students.

PARTICIPANTS

266 pre-health undergraduate students attending a Hispanic-Serving Institution in South Texas.

METHODS

We conducted a cross-sectional, online survey with a purposive sample of undergraduate students and analyzed data descriptively.

RESULTS

Most students desired children in the future but were concerned about planning the timing of parenthood against their career training. The results highlight the need to improve both family planning and fertility knowledge, based on a high unmet need for contraceptives, low perceived knowledge about fertility/infertility treatment, and a desire to learn more about planning the timing of their career training alongside parenthood.

CONCLUSIONS

This study highlights potential gaps in reproductive health information and services among diverse, health-focused students needed to inform choices about the timing of their families and career training.

Innovation to Impact: Introduction to the Special Issue on Evidence from the Teen Pregnancy Prevention Program Experiment with Innovation

Congress has provided funding for the federal Teen Pregnancy Prevention (TPP) Program since 2009 for spending beginning in Fiscal Year 2010. Designated TPP programs develop, test, and evaluate innovations for reducing teen pregnancy, teen pregnancy disparities, and associated risk factors and for promoting positive youth development. Since its inception, the TPP Program has experimented with multiple uniquely structured cohorts of innovation and demonstration projects, producing critical insights into equitable and effective public health innovation while also serving as a highly productive contributor of evidence-based, TPP innovations for scale. This article briefly documents the innovation history of the TPP Program and its iterations in response to the shifting needs of the field. We then synthesize findings from the fifteen TPP innovators published in this special edition. We highlight emergent priorities of the TPP Program informed by this federal experiment in rigorous adolescent sexual health innovation development, testing, evaluation, and scaling and conclude by discussing how the TPP program adapted and refined its approach for fostering dynamic innovation-to-scale projects over time.

A Meta-Analysis of the Effects of Comprehensive Sexuality Education Programs on Children and Adolescents

Childhood and adolescence are crucial periods for developing one's awareness of sexuality. Comprehensive Sexuality Education (CSE) during these stages is essential for overall growth, fostering healthy self-concepts, and addressing diverse sexual issues among children and adolescents globally. A meta-analysis was conducted to analyze the effectiveness of CSE programs. A literature search was performed on EMBASE, PubMed, CINAHL, Cochrane Library, and PsycInfo for studies published before 14 June 2023, and based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the Comprehensive Meta-Analysis (CMA, V4) software version 4.0 for the analysis and interpreted the effect sizes according to Cohen's definition. Between 2011 and 2020, 21 studies on CSE were published, with the United States having the most publications (17). Of the 34 studies reviewed, 20 were randomized controlled trials. The primary population for CSE was middle/high school students (15), with the most frequent age range being 10-19 years (26). The overall effect size of CSE was significant (effect size = 1.31, p < 0.001), with cognition (effect size = 5.76, p < 0.001) being the most significant. CSE is an effective educational tool for children and adolescents with a significant impact on variables such as cognition and abstinence. It should be incremental from childhood and adolescence to adulthood.

Mobile phone-based interventions for improving contraception use

BACKGROUND

Contraception provides significant benefits for women's and children's health, yet many women have an unmet need for contraception. Rapid expansion in the use of mobile phones in recent years has had a dramatic impact on interpersonal communication. Within the health domain text messages and smartphone applications offer means of communication between clients and healthcare providers. This review focuses on interventions delivered by mobile phone and their effect on use of contraception.

OBJECTIVES

To evaluate the benefits and harms of mobile phone-based interventions for improving contraception use.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was August 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of mobile phone-based interventions to improve forms of contraception use amongst users or potential users of contraception.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. uptake of contraception, 2. uptake of a specific method of contraception, 3. adherence to contraception method, 4. safe method switching, 5. discontinuation of contraception and 6. pregnancy or abortion. Our secondary outcomes were 7. road traffic accidents, 8. any physical or psychological effect reported and 9. violence or domestic abuse.

MAIN RESULTS

Twenty-three RCTs (12,793 participants) from 11 countries met our inclusion criteria. Eleven studies were conducted in high-income resource settings and 12 were in low-income settings. Thirteen studies used unidirectional text messaging-based interventions, six studies used interactive text messaging, four used voice message-based interventions and two used mobile-phone apps to improve contraception use. All studies received funding from non-commercial bodies. Mobile phone-based interventions probably increase contraception use compared to the control (odds ratio (OR) 1.30, 95% confidence interval (CI) 1.06 to 1.60; 16 studies, 8972 participants; moderate-certainty evidence). There may be little or no difference in rates of unintended pregnancy with the use of mobile phone-based interventions compared to control (OR 0.82, 95% CI 0.48 to 1.38; 8 trials, 2947 participants; moderate-certainty evidence). Subgroup analysis assessing unidirectional mobile phone interventions versus interactive mobile phone interventions found evidence of a difference between the subgroups favouring interactive interventions (P = 0.003, I2 = 88.5%). Interactive interventions had an OR of 1.71 (95% CI 1.28 to 2.29; P = 0.0003, I2 = 63%; 8 trials, 3089 participants) whilst unidirectional interventions had an OR of 1.03 (95% CI 0.87 to 1.22; P = 0.72, I2 = 17%; 9 trials, 5883 participants). Subgroup analysis assessing high-income versus low-income trial settings found no difference between groups (subgroup difference test: P = 0.70, I2 = 0%). Only six trials reported on safety and unintended outcomes; one trial reported increased partner violence whilst another four trials reported no difference in physical violence rates between control and intervention groups. One trial reported no road traffic accidents with mobile phone intervention use.

AUTHORS' CONCLUSIONS

This review demonstrates there is evidence to support the use of mobile phone-based interventions in improving the use of contraception, with moderate-certainty evidence. Interactive mobile phone interventions appear more effective than unidirectional methods. The cost-effectiveness, cost benefits, safety and long-term effects of these interventions remain unknown, as does the evidence of this approach to support contraception use among specific populations. Future research should investigate the effectiveness and safety of mobile phone-based interventions with better quality trials to help establish the effects of interventions delivered by mobile phone on contraception use. This review is limited by the quality of the studies due to flaws in methodology, bias or imprecision of results.

A virtual randomized controlled trial of an alcohol-exposed pregnancy prevention mobile app with urban American Indian and Alaska Native young women: Native WYSE CHOICES rationale, design, and methods

BACKGROUND

Fetal Alcohol Spectrum Disorders (FASD) result in lifelong disability and are a leading cause of preventable birth defects in the US, including for American Indian and Alaska Natives (AIANs). Prevention of alcohol exposed pregnancies (AEPs), which can cause FASD, is typically aimed at adult women who are risky drinkers and have unprotected sex. Among AIANs, AEP prevention research has been primarily conducted in reservation communities, even though over 70% of AIANs live in urban areas. Culturally appropriate AEP prevention for urban AIAN young women, regardless of current drinking or sexual behaviors, may maximize the potential for primary prevention at the beginning of the reproductive years for this underserved population.

METHODS

We developed a virtual randomized controlled trial (RCT) - fully implemented through technology - to evaluate Native WYSE CHOICES, a culturally tailored mobile app, with urban AIAN young women ages 16-20 nationally. While virtual RCTs are not new, this is the first engaging a solely urban AIAN population, historically excluded from research. Participants are recruited on a rolling basis through the project social media community, organizational partnerships, and in-person events. Eligible participants complete a baseline survey and are randomized to either the app's intervention or comparison arm - each of which provide about 3 h of content. Follow-up data are collected at 1-, 6-, and 12-months post-baseline.

RESULTS

Our study offers a template for building trust and extending reach to this underserved population while also providing important lessons and insights on advances in virtual or hybrid research approaches.

Redefining venereology practice in Tamil Nadu, South India - Nakshatra Health - A networking model

Background

Accessing care for sexual health has always been a challenge in our Indian context. The primary reason is a lack of awareness of modes of transmission of sexually transmitted diseases (STD), appropriate testing, and treatment options. The second is taboo associated with the morality of the individual. The third is the accessibility and availability of Quality STD care by allopathic specialists in comparison to the demand. This has paved way for lots of myths and misconceptions among the general public regarding STDs and HIV disease. Compounding it is the mushrooming of nonqualified practitioners and healers who claim to cure all STDs and HIV has led to poor treatment outcomes. Several methods of partnership with qualified allopathic practitioners have been tried for the provision of quality STD care by various donor-funded, HIV and STD prevention programs in the country. The key reasons for the nonsustainability of these clinics were the lack of technical capability to handle the sexual health and STD clinical cases and the huge cost involved in the advertisement and maintenance of the clinics.

Methodology

Seven clinicians from different geographical locations in Tamil Nadu, who were exclusively qualified in Venereology, conceived the idea of provision of comprehensive clinical care cum counseling and testing services through a networking model from December 01, 2020. The model comprised the following: (1) Dedicated YouTube channel (Nakshatra Health) to provide scientific information on STD and HIV, modes of transmission, clinical symptoms, lab testing, interpretation of results, clinical treatment options, and counseling on prevention, (2) Dedicated telephone helpline was established with WhatsApp to answer the queries of clients by the network venereologists, (3) Dedicated website (www.nakshatra.health) was developed to provide information on STD and HIV and options to clarify doubts and fix appointments online, (4) Clinical consultations were done in a hybrid mode with an option for direct clinic and online consultation. Prescriptions were provided using dedicated software instantly, (5) Networking was done with NABL-accredited labs and collection centers for performing STD and HIV tests with e-test request forms, (6) Networking was done with pharma companies to provide pre- and postexposure prophylaxis (PEP) services to clients through e-prescriptions. Cross referrals were made across the network members to facilitate easy access to clinical services by clients from different parts of Tamil Nadu. The entire concept was branded as "Nakshatra health" with a tagline - "Your sparkling solution for safe sexual health care." Quality STD care and ethical practice were the underlying motos of this concept.

Results

During the 20 months (December 2020 to July 2022), 6442 phone calls and 9328 WhatsApp messages were received. 82.3% of the calls and messages were queries from clients related to their sexual exposures, and 16.4% were general information seekers. During this period, the Nakshatra Health YouTube channel had 1590 subscribers and nearly 2.4 lakh views of all its 24 videos. Among the viewers, 92.4% were male. 52.29% of viewers were between the ages of 25 and 34 years, 28.25% were between the ages of 18 and 24 years, and 17.25% viewers were between the ages of 35 and 44 years. 86% of the viewers were from India and 13% were Tamil-speaking viewers from Middle East, Southeast Asian countries and 1% were from European, African, and American countries. The most commonly watched videos were related to HIV symptoms and lab tests for STD and HIV. 16% of the viewers repeatedly watched the various videos in the series. The network laboratories provided testing services for 1082 clients with 2423 various STD/HIV tests. Totally 3328 clients availed of online consultation and 924 clients accessed clinic-based services across the network members. Among these cases, 18 cases of Syphilis (primary and secondary) and 12 cases of acute gonococcal urethritis, and 10 cases of genital warts were diagnosed and treated. 12 cases of phimosis and 4 cases of anal warts were surgically treated in collaboration with a surgeon. Through this initiative, PEP and PreP services were provided to 228 and 8 individuals.

Conclusion

Designing a comprehensive sexual health service package is crucial to ensure the availability and ease of access to services to the general public. Provision of correct scientific information, networking and cross-referral of cases with like-minded dermatovenereologists/clinicians interested in venereology sexually transmitted infections, easily accessible clinical, laboratory, and treatment services including PreP and PEP medications, and ethical practice are the key factors for scaling this concept.

Enrollment and Retention of Participants in Remote Digital Health Studies: Scoping Review and Framework Proposal

BACKGROUND

Digital technologies are increasingly used in health research to collect real-world data from wider populations. A new wave of digital health studies relies primarily on digital technologies to conduct research entirely remotely. Remote digital health studies hold promise to significant cost and time advantages over traditional, in-person studies. However, such studies have been reported to typically suffer from participant attrition, the sources for which are still largely understudied.

OBJECTIVE

To contribute to future remote digital health study planning, we present a conceptual framework and hypotheses for study enrollment and completion. The framework introduces 3 participation criteria that impact remote digital health study outcomes: (1) participant motivation profile and incentives or nudges, (2) participant task complexity, and (3) scientific requirements. The goal of this study is to inform the planning and implementation of remote digital health studies from a person-centered perspective.

METHODS

We conducted a scoping review to collect information on participation in remote digital health studies, focusing on methodological aspects that impact participant enrollment and retention. Comprehensive searches were conducted on the PubMed, CINAHL, and Web of Science databases, and additional sources were included in our study from citation searching. We included digital health studies that were fully conducted remotely, included information on at least one of the framework criteria during recruitment, onboarding or retention phases of the studies, and included study enrollment or completion outcomes. Qualitative analyses were performed to synthesize the findings from the included studies.

RESULTS

We report qualitative findings from 37 included studies that reveal high values of achieved median participant enrollment based on target sample size calculations, 128% (IQR 100%-234%), and median study completion, 48% (IQR 35%-76%). Increased median study completion is observed for studies that provided incentives or nudges to extrinsically motivated participants (62%, IQR 43%-78%). Reducing task complexity for participants in the absence of incentives or nudges did not improve median study enrollment (103%, IQR 102%-370%) or completion (43%, IQR 22%-60%) in observational studies, in comparison to interventional studies that provided more incentives or nudges (median study completion rate of 55%, IQR 38%-79%). Furthermore, there were inconsistencies in measures of completion across the assessed remote digital health studies, where only around half of the studies with completion measures (14/27, 52%) were based on participant retention throughout the study period.

CONCLUSIONS

Few studies reported on participatory factors and study outcomes in a consistent manner, which may have limited the evidence base for our study. Our assessment may also have suffered from publication bias or unrepresentative study samples due to an observed preference for participants with digital literacy skills in digital health studies. Nevertheless, we find that future remote digital health study planning can benefit from targeting specific participant profiles, providing incentives and nudges, and reducing study complexity to improve study outcomes.

Future Directions in Mental Health Treatment with Stigmatized Youth

Stigma refers to societally-deemed inferiority associated with a circumstance, behavior, status, or identity. It manifests internally, interpersonally, and structurally. Decades of research indicate that all forms of stigma are associated with heightened risk for mental health problems (e.g., depression, PTSD, suicidality) in stigmatized youth (i.e., children, adolescents, and young adults with one or more stigmatized identities, such as youth of Color and transgender youth). Notably, studies find that stigmatized youth living in places with high structural stigma - defined as laws/policies and norms/attitudes that hurt stigmatized people - have a harder time accessing mental health treatment and are less able to benefit from it. In order to reduce youth mental health inequities, it is imperative for our field to better understand, and ultimately address, stigma at each of these levels. To facilitate this endeavor, we briefly review research on stigma and youth mental health treatment, with an emphasis on structural stigma, and present three future directions for research in this area: (1) directly addressing stigma in treatment, (2) training therapists in culturally responsive care, and (3) structural interventions. We conclude with recommendations for best practices in broader mental health treatment research.

Viewpoint: digital paediatrics-so close yet so far away

Technology is driving a revolution in healthcare, but paediatric services have not fully harnessed the potential. Digital health solutions yet to achieve their promise in paediatrics include electronic health records, decision support systems, telemedicine and remote consultations, despite the accelerated uptake during the COVID-19 pandemic. There are also significant potential benefits in digitally enabled research, including systems to identify and recruit participants online or through health records, tools to extract data points from routine data sets rather than new data collection, and remote approaches to outcome measurement. Children and their families are increasingly becoming digital health citizens, able to manage their own health and use of health services through mobile apps and wearables such as fitness trackers. Ironically, one barrier to the uptake of these technologies is that the fast pace of change in this area means the evidence base behind many of these tools remains underdeveloped. Clinicians are often sceptical of innovations which appear largely driven by enthusiasts rather than science. Rigorous studies are needed to demonstrate safety and effectiveness. Regulators need to be agile and responsive. Implementation needs adequate resource and time, and needs to minimise risks and address concerns, such as worries over losing human contact. Digital health care needs to be embedded in medical education and training so that clinicians are trained in the use of innovations and can understand how to embed within services. In this way, digital paediatrics can deliver benefits to the profession, to services and to our patients.

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.

m-Health en intervenciones para incrementar el uso de anticonceptivos en adolescentes latinas: revisión de alcance

Objetivo Mapear la forma de uso y el efecto de las tecnologías m-Health en intervenciones a fin de incrementar el uso de anticonceptivos en adolescentes latinas. Métodos Se realizó una revisióón de alcance a partir de Peters M en octubre de 2021; se recuperaron artículos del 2015 a 2021 en EBSCO Host, PubMed y BVS, LILACS, SciELO, Web of Science y Scopus, en inglés, español y portugués. Resultados Se identificaron ocho artículos que emplearon las m-Health como potencializadoras. La forma de uso fue ampliamente heterogénea en dosis, intervalo e interacción. El efecto significativo para el uso de anticonceptivos fue reportado en tres diseños experimentales, con una buena aceptabilidad y viabilidad para futuros experimentos. Discusión Las m-Health ofrecen una oportunidad de incrementar el uso de anticon-ceptivos en adolescentes. Al momento, su efecto es controversial debido a la escasez de intervenciones de este tipo. Por lo tanto, se requieren estudios rigurosos que consideren procesos de adaptación a contextos latinos

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

BACKGROUND

Adolescent females presenting to emergency departments (EDs) inconsistently use contraceptives. We aimed to assess implementation outcomes and potential efficacy of a user-informed, theory-based digital health intervention developed to improve sexual and reproductive health for adolescent females in the ED.

METHODS

We conducted a pilot-randomized controlled trial of sexually active female ED patients age 14-19 years. Participants were randomized to the intervention Dr. Erica (Emergency Room Interventions to improve the Care of Adolescents) or usual care. Dr. Erica consists of an ED-based digital intervention along with 3 months of personalized and interactive multimedia messaging. We assessed the feasibility, adoption, and fidelity of Dr. Erica among adolescent female users. Initiation of highly effective contraception was the primary efficacy outcome.

RESULTS

We enrolled 146 patients; mean (±SD) age was 17.7 (±1.27) years and 87% were Hispanic. Dr. Erica demonstrated feasibility, with high rates of consent (84.4%) and follow-up (82.9%). Intervention participants found Dr. Erica acceptable, liking (98.0%, on Likert scale) and recommending (83.7%) the program. A total of 87.5% adopted the program, responding to at least one text; a total of 289 weblinks were clicked. Dr. Erica demonstrated fidelity; few participants opted out (6.9%) and failed to receive texts (1.4%). Contraception was initiated by 24.6% (14/57) in the intervention and 21.9% (14/64) in the control arms (absolute risk difference [ARD] = 2.7%, 95% confidence interval [CI] = -12.4% to 17.8%). Participants receiving Dr. Erica were more likely to choose a method to start in the future (65.9% [27/41]) than controls (30.0% [15/50]); ARD = 35.9%, 95% CI = 16.6% to 55.1%).

CONCLUSIONS

A personalized, interactive digital intervention was feasible to implement, acceptable to female ED patients and demonstrated high fidelity and adoption. This ED-based intervention shows potential to improve contraception decision making.

A Pilot RCT Evaluating InThistoGether, an mHealth HIV Prevention Program for Ugandan Youth

Despite data suggesting that older adolescence is an important period of risk for HIV acquisition in Uganda, tailored HIV prevention programming is lacking. To address this gap, we developed and tested nationally, InThistoGether (ITG), a text messaging-based HIV prevention program for 18-22 year-old Ugandan youth. To assess feasibility and acceptability, and preliminary indications of behavior change, a randomized controlled trial was conducted with 202 youth. Participants were assigned either to ITG or an attention-matched control group that promoted general health (e.g., self-esteem). They were recruited between December 2017 and April 2018 on Facebook and Instagram, and enrolled over the telephone. Between 5-10 text messages were sent daily for seven weeks. Twelve weeks later, the intervention ended with a one-week 'booster' that reviewed the main program topics. Measures were assessed at baseline and intervention end, 5 months post-randomization. Results suggest that ITG is feasible: The retention rate was 83%. Ratings for the content and program features met acceptability thresholds; program experience ratings were mixed. ITG also was associated with significantly higher rates of condom-protected sex (aIRR = 1.68, p < 0.001) and odds of HIV testing (aOR = 2.41, p = 0.03) compared to the control group. The odds of abstinence were similar by experimental arm however (aOR = 1.08, p = 0.86). Together, these data suggest reason for optimism that older adolescent Ugandans are willing to engage in an intensive, text messaging-based HIV prevention programming. Given its wide reach and low cost, text messaging should be better utilized as an intervention delivery tool in low-income settings like Uganda. Findings also suggest that ITG may be associated with behavior change in the short-term. (Trial registration: ClinicalTrials.gov ID# NCT02729337).