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Aboye GT, Simegn GL, Aerts JM. Assessment of the Barriers and Enablers of the Use of mHealth Systems in Sub-Saharan Africa According to the Perceptions of Patients, Physicians, and Health Care Executives in Ethiopia: Qualitative Study. J Med Internet Res 2024; 26:e50337. [PMID: 38536231 PMCID: PMC11007608 DOI: 10.2196/50337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/01/2023] [Accepted: 02/13/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Digital technologies are increasingly being used to deliver health care services and promote public health. Mobile wireless technologies or mobile health (mHealth) technologies are particularly relevant owing to their ease of use, broad reach, and wide acceptance. Unlike developed countries, Sub-Saharan Africa experiences more challenges and obstacles when it comes to deploying, using, and expanding mHealth systems. In addition to barriers, there are enabling factors that could be exploited for the design, implementation, and scaling up of mHealth systems. Sub-Saharan Africa may require tailored solutions that address the specific challenges facing the region. OBJECTIVE The overall aim of this study was to identify the barriers and enablers for using mHealth systems in Sub-Saharan Africa from the perspectives of patients, physicians, and health care executives. METHODS Multi-level and multi-actor in-depth semistructured interviews were employed to qualitatively explore the barriers and enablers of the use of mHealth systems. Data were collected from patients, physicians, and health care executives. The interviews were audio recorded, transcribed verbatim, translated, and coded. Thematic analysis methodology was adopted, and NVivo software was used for the data analysis. RESULTS Through this rigorous study, a total of 137 determinants were identified. Of these determinants, 68 were identified as barriers and 69 were identified as enablers. Perceived barriers in patients included lack of awareness about mHealth systems and language barriers. Perceived enablers in patients included need for automated tools for health monitoring and an increasing literacy level of the society. According to physicians, barriers included lack of available digital health systems in the local context and concern about patients' mHealth capabilities, while enablers included the perceived usefulness in reducing workload and improving health care service quality, as well as the availability of mobile devices and the internet. As perceived by health care executives, barriers included competing priorities alongside digitalization in the health sector and lack of interoperability and complete digitalization of implemented digital health systems, while enablers included the perceived usefulness of digitalization for the survival of the highly overloaded health care system and the abundance of educated manpower specializing in technology. CONCLUSIONS mHealth systems in Sub-Saharan Africa are hindered and facilitated by various factors. Common barriers and enablers were identified by patients, physicians, and health care executives. To promote uptake, all relevant stakeholders must actively mitigate the barriers. This study identified a promising outlook for mHealth in Sub-Saharan Africa, despite the present barriers. Opportunities exist for successful integration into health care systems, and a user-centered design is crucial for maximum uptake.
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Affiliation(s)
- Genet Tadese Aboye
- M3-BIORES (Measure, Model & Manage Bioreponses), Division of Animal and Human Health Engineering, Department of Biosystems, KU Leuven, Leuven, Belgium
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
| | | | - Jean-Marie Aerts
- M3-BIORES (Measure, Model & Manage Bioreponses), Division of Animal and Human Health Engineering, Department of Biosystems, KU Leuven, Leuven, Belgium
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Dratva J, Schaeffer D, Zeeb H. [Digital health literacy in Germany: current status, concepts, and challenges]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2024; 67:277-284. [PMID: 38315221 DOI: 10.1007/s00103-024-03841-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/25/2024] [Indexed: 02/07/2024]
Abstract
A key prerequisite for the successful digital transformation of the healthcare system is a well-developed level of digital health literacy (DHL) among the population. DHL is the ability to deal with health-relevant digital information and information options with the aim of promoting and maintaining health and well-being for oneself and one's environment. This article examines the discussions about digital health literacy, the existing studies and measurement tools used in them, the data situation in Germany, and current challenges.DHL consists of various sub-competencies that reflect current digital information behavior, opportunities, and risks. The data situation is very heterogeneous due to different study designs and instruments, which limits the informative value. Two representative studies, HLS-Ger‑2 by Bielefeld University and the study by AOK Rheinland/Hamburg and the Leibniz-WissenschaftsCampus, both indicate a high proportion of people with low DHL despite different methods. Both nationally and internationally, DHL is subject to a social gradient and is associated with educational level, social status, financial deprivation, and age.According to the current empirical data, the acquisition of DHL in Germany is still insufficient, so there is a great need for action. The necessary legal framework conditions have been established, but there is still a lack of reliable and financial resources, as well as a solid data basis on DHL at population level. This is essential to identify vulnerability factors and to prepare and evaluate the implementation of measures. In addition, there is a need for an in-depth conceptual discussion on DHL that builds on the established health literacy concept and addresses the emerging health-related infodemic and its consequences for DHL.
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Affiliation(s)
- Julia Dratva
- Institut für Public Health, ZHAW Zürcher Hochschule für Angewandte Wissenschaften, Katharina-Sulzer-Platz 9, 8400, Winterthur, Schweiz.
- Fakultät Medizin, Universität Basel, Basel, Schweiz.
| | - Doris Schaeffer
- Fakultät für Gesundheitswissenschaften, Universität Bielefeld, Bielefeld, Deutschland
| | - Hajo Zeeb
- Leibniz ScienceCampus Digital Public Health, Leibniz-Institut für Präventionsforschung und Epidemiologie - BIPS, Bremen, Deutschland
- Health Sciences Bremen, Universität Bremen, Bremen, Deutschland
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Larsson L, Chikwari CD, McHugh G, Koris A, Bandason T, Dauya E, Mapani L, Abrahams M, Shankland L, Simms V, Tembo M, Mavodza C, Kranzer K, Ferrand RA. Feasibility and Usability of Mobile Technology to Assist HIV Self-Testing in Youth in Zimbabwe: A Mixed-Methods Study. J Adolesc Health 2023; 73:553-560. [PMID: 37389521 DOI: 10.1016/j.jadohealth.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 04/29/2023] [Accepted: 05/07/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE Mobile technology is increasingly being used to widen access to and support the delivery of public health interventions. Human immunodeficiency viruses (HIV) self-testing (HIVST) enables individuals to have autonomy. We evaluated the feasibility of a novel application called ITHAKA to support HIVST among youth aged 16-24 years in Zimbabwe. METHODS This study was nested within a trial of community-based delivery of integrated HIV and sexual and reproductive health services called CHIEDZA. Youth accessing CHIEDZA were offered provider-delivered HIV testing or HIVST supported by ITHAKA, either on a tablet on-site at a community centre or on their mobile phone off-site. ITHAKA incorporated pre and post-test counselling, and instructions for conducting the test and the appropriate actions to take depending on test result, including reporting HIV test results to health providers. The outcome was completion of the testing journey. Semistructured interviews with CHIEDZA providers explored the perceptions of and experiences with the application. RESULTS Between April and September 2019, of the 2,181 youth who accepted HIV testing in CHIEDZA, 128 (5.8%) initiated HIVST (the remainder opting for provider-delivered testing) using ITHAKA. Nearly all who performed HIVST on-site (108/109 (99.1%)) compared to only 9/19 (47.4%) who tested off-site completed their testing journey. Low digital literacy, lack of agency, erratic network coverage, lack of dedicated phone ownership, the limited functionality of smartphones challenged implementation of ITHAKA. DISCUSSION Digitally supported HIVST had low uptake among youth. The feasibility and usability of digital interventions should be carefully assessed before implementation, paying careful attention to digital literacy, network availability, and access to devices.
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Affiliation(s)
- Leyla Larsson
- Health Research Institute, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Chido Dziva Chikwari
- Health Research Institute, Biomedical Research and Training Institute, Harare, Zimbabwe; Department of Infectious Disease Epidemiology, MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Grace McHugh
- Health Research Institute, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Andrea Koris
- Health Research Institute, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Tsitsi Bandason
- Health Research Institute, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Ethel Dauya
- Health Research Institute, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Lyanne Mapani
- Aviro Health, Cape Town, South Africa; Global Health and Development Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Musaed Abrahams
- Aviro Health, Cape Town, South Africa; Global Health and Development Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Luke Shankland
- Aviro Health, Cape Town, South Africa; Global Health and Development Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Victoria Simms
- Health Research Institute, Biomedical Research and Training Institute, Harare, Zimbabwe; Department of Infectious Disease Epidemiology, MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mandikudza Tembo
- Health Research Institute, Biomedical Research and Training Institute, Harare, Zimbabwe; Department of Infectious Disease Epidemiology, MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Constancia Mavodza
- Health Research Institute, Biomedical Research and Training Institute, Harare, Zimbabwe; Department of Environments, Public health and Society, London School of Hygiene Tropical Medicine, London, United Kingdom
| | - Katharina Kranzer
- Health Research Institute, Biomedical Research and Training Institute, Harare, Zimbabwe; Clinical Research Department, London School of Hygiene Tropical Medicine, London, United Kingdom; Department of Infectious Diseases & Tropical Medicine, Ludwig Maximilian University of Munich, Munich, Germany
| | - Rashida Abbas Ferrand
- Health Research Institute, Biomedical Research and Training Institute, Harare, Zimbabwe; Clinical Research Department, London School of Hygiene Tropical Medicine, London, United Kingdom.
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Adebayo ES, Wang D, Olaniyan HO, Olumide AO, Ogunniyi A, Fawzi W. Scalability of mobile technology interventions in the prevention and management of HIV among adolescents in low-income and middle-income countries: protocol for a systematic review. BMJ Open 2023; 13:e069362. [PMID: 37451733 PMCID: PMC10351258 DOI: 10.1136/bmjopen-2022-069362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION The rate of new infections with HIV remains high among adolescents globally. Adolescents in low-income and middle-income countries (LMICs), who are least likely to have access to quality healthcare, have the highest proportion of those living with HIV. Mobile technology has played an important role in providing access to information and services among adolescents in recent years. This review aims to synthesise and summarise information that will be useful in the planning, designing and implementing of future mHealth strategies. METHODS AND ANALYSIS Interventional studies, reported in English, on the prevention and management of HIV among adolescents that used mobile technology in LMICs will be included. MEDLINE (via PubMed), Embase, Web of Science, CINAHL, Clinicaltrials.gov, WHO International Clinical Trials Registry Platform (ICTRP), and the Cochrane Library are the information sources that have been identified as relevant to the area of study. These sources will be searched from inception to March 2023. The risk of bias will be assessed using the Cochrane Risk of Bias tool. The scalability of each study will be assessed using the Intervention Scalability Assessment Tool. Two independent reviewers will conduct the selection of studies, data extraction, and assessment of the risk of bias and scalability. A narrative synthesis of all the included studies will be done. ETHICS AND DISSEMINATION Ethical approval was not necessary for this study. This is a systematic review of publicly available information and therefore ethical approval was not deemed necessary. The results of this review will be published in a peer reviewed journal. TRIAL REGISTRATION This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42022362130.
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Affiliation(s)
- Emmanuel S Adebayo
- Institute of Child Health, University of Ibadan College of Medicine, Ibadan, Nigeria
| | - Dongqing Wang
- Global and Community Health, George Mason University College of Health and Human Services, Fairfax, Virginia, USA
| | | | | | - Adesola Ogunniyi
- Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | - Wafaie Fawzi
- Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, USA
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Kisigo GA, Mgeta F, Mcharo O, Okello E, Wajanga B, Kalokola F, Mtui G, Sundararajan R, Peck RN. Peer Counselor Intervention for Reducing Mortality and/or Hospitalization in Adults With Hypertensive Urgency in Tanzania: A Pilot Study. Am J Hypertens 2023; 36:446-454. [PMID: 37086189 PMCID: PMC10345467 DOI: 10.1093/ajh/hpad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/27/2023] [Accepted: 04/19/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND Worldwide, people with hypertensive urgency experience high rates of hospitalization and death due to medication non-adherence. Interventions to improve medication adherence and health outcomes after hypertensive urgency are urgently needed. METHODS This prospective cohort assessed the effect of a peer counselor intervention-named Rafiki mwenye msaada-on the 1-year incidence of hospitalization and/or death among adults with hypertensive urgency in Mwanza, Tanzania. We enrolled 50 patients who presented with hypertensive urgency to 2 hospitals in Mwanza, Tanzania. All 50 patients received a Rafiki mwenye msaada an individual-level, time-limited case management intervention. Rafiki mwenye msaada aims to empower adult patients with hypertensive urgency to manage their high blood pressure. It consists of 5 sessions delivered over 3 months by a peer counselor. Outcomes were compared to historical controls. RESULTS Of the 50 patients (median age, 61 years), 34 (68%) were female, and 19 (38%) were overweight. In comparison to the historical controls, the intervention cohort had a significantly lower proportion of patients with a secondary level of education (22% vs. 35%) and health insurance (40% vs. 87%). Nonetheless, the 1-year cumulative incidence of hospitalization and/or death was 18% in the intervention cohort vs. 35% in the control cohort (adjusted Hazard Ratio, 0.48, 95% CI 0.24-0.97; P = 0.041). Compared to historical controls, intervention participants maintained higher rates of medication use and clinic attendance at both 3- and 6-months but not at 12 months. Of intervention participants who survived and remained in follow-up, >90% reported good medication adherence at all follow-up time points. CONCLUSION Our findings support the hypothesis that a peer counselor intervention may improve health outcomes among adults living with hypertensive urgency. A randomized clinical trial is needed to evaluate the intervention's effectiveness.
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Affiliation(s)
- Godfrey A Kisigo
- Center for Global Health, Weill Cornell Medicine, New York, New York, USA
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Frank Mgeta
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Onike Mcharo
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Elialilia Okello
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Bahati Wajanga
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Fredrick Kalokola
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Graham Mtui
- Department of Internal Medicine, Sekou Touré Referral Regional Hospital, Mwanza, Tanzania
| | - Radhika Sundararajan
- Center for Global Health, Weill Cornell Medicine, New York, New York, USA
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Robert N Peck
- Center for Global Health, Weill Cornell Medicine, New York, New York, USA
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
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Lowenthal ED, DeLong SM, Zanoni B, Njuguna I, Beima-Sofie K, Dow D, Shayo A, Schreibman A, Ahmed CV, Chapman J, Chen L, Mehta S, Mbizvo MT. Impact of COVID-19 on Adolescent HIV Prevention and Treatment Research in the AHISA Network. AIDS Behav 2023; 27:73-83. [PMID: 36094636 PMCID: PMC9466311 DOI: 10.1007/s10461-022-03811-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2022] [Indexed: 11/09/2022]
Abstract
Members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) network conduct research aiming to close gaps between what is known to be impactful across the HIV prevention and treatment cascade, and services delivered to optimize outcomes for adolescents/young adults (AYA) in high HIV-prevalence settings. The COVID-19 pandemic introduced new challenges which threaten to exacerbate care and access disparities. We report results of a survey among AHISA teams with active AYA HIV research programs in African countries to determine how the pandemic has impacted their efforts. Results highlighted the detrimental impact of the pandemic on research efforts and the expanded need for implementation research to help provide evidence-based, context-specific pandemic recovery support. Key lessons learned included the viability of remote service delivery strategies and other innovations, the need for adaptive systems that respond to evolving contextual needs, and the need for organized documentation plans, within empathic and flexible environments.
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Affiliation(s)
- Elizabeth D Lowenthal
- Departments of Pediatrics and Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Children's Hospital of Philadelphia Global Health Center, Philadelphia, USA.
- CHOP Roberts Center for Pediatric Research, Room 11241, 734 Schuylkill Ave, Philadelphia, PA, 19146, USA.
| | - Stephanie M DeLong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Brian Zanoni
- Departments of Medicine and Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Irene Njuguna
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Dorothy Dow
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Global Health Institute, Durham, NC, USA
| | - Aisa Shayo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | - Charisse V Ahmed
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Jennifer Chapman
- Children's Hospital of Philadelphia Global Health Center, Philadelphia, USA
| | - Lydia Chen
- University of Pennsylvania, Philadelphia, PA, USA
| | - Shreya Mehta
- University of Pennsylvania, Philadelphia, PA, USA
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Wang D, Shinde S, Drysdale R, Vandormael A, Tadesse AW, Sherfi H, Tinkasimile A, Mwanyika‐Sando M, Moshabela M, Bärnighausen T, Sharma D, Fawzi WW. Access to digital media and devices among adolescents in sub‐Saharan Africa: A multicountry, school‐based survey. MATERNAL & CHILD NUTRITION 2023:e13462. [DOI: 10.1111/mcn.13462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 04/08/2023]
Affiliation(s)
- Dongqing Wang
- Department of Global and Community Health, College of Public Health George Mason University Fairfax Virginia USA
| | - Sachin Shinde
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health Harvard University Boston Massachusetts USA
- Center for Inquiry into Mental Health Pune India
| | - Roisin Drysdale
- DSI‐NRF Centre of Excellence in Human Development University of the Witwatersrand Johannesburg South Africa
| | - Alain Vandormael
- Heidelberg Institute of Global Health Heidelberg University Heidelberg Germany
| | - Amare W. Tadesse
- Department of Infectious Disease Epidemiology London School of Hygiene and Tropical Medicine London UK
- Addis Continental Institute of Public Health Addis Ababa Ethiopia
| | - Huda Sherfi
- School of Health Sciences Ahfad University for Women Omdurman Sudan
| | | | | | - Mosa Moshabela
- School of Nursing and Public Health University of KwaZulu‐Natal Durban South Africa
- Africa Health Research Institute Durban South Africa
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health Harvard University Boston Massachusetts USA
- Heidelberg Institute of Global Health Heidelberg University Heidelberg Germany
- Africa Health Research Institute Durban South Africa
| | - Deepika Sharma
- Nutrition Programme Division UNICEF New York New York USA
| | - Wafaie W. Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health Harvard University Boston Massachusetts USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health Harvard University Boston Massachusetts USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health Harvard University Boston Massachusetts USA
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Adebayo E, Wang D, Olumide AO, Ogunniyi A, Fawzi W. Scalability of mobile technology interventions in the prevention and management of HIV among adolescents in low- and middle-income countries: protocol for a systematic review. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.21.23287533. [PMID: 36993161 PMCID: PMC10055572 DOI: 10.1101/2023.03.21.23287533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Introduction The rate of new infection of HIV is still high among adolescents globally. Adolescents in low and middle-income countries (LMICs) who are least likely to have access to quality healthcare have the highest proportion of those living with HIV. Mobile technology has played an important role in providing access to information and services among adolescents within the region in recent years. This review aims to synthesise and summarise information that will be useful in planning, designing, and implementing future mHealth strategies within the region. Methods and Analysis Interventional studies on the prevention and management of HIV among adolescents that used mobile technology in LMICs will be included. MEDLINE (via PubMed), EMBASE, Web of Science, CINAHL, and the Cochrane Library are the information sources that have been identified as relevant to the area of study. These sources will be searched from inception to March 2023. The risk of bias will be assessed using the Cochrane Risk of Bias tool. The scalability of each study will be assessed using the Intervention Scalability Assessment Tool (ISAT). Two independent reviewers will conduct the selection of studies, data extraction, assessment of the risk of bias, and scalability. A narrative synthesis of all the included studies will be provided through a table. Ethics and dissemination An ethical approval was not necessary for this study. This is a systematic review of publicly available information and therefore ethical approval was not deemed necessary. The results of this review will be published in a peer reviewed journal and dataset will be presented in the main manuscript. Strengths and limitations We believe that the likelihood of missing any published article will be low because of the information sources we are considering.The scalability tool (ISAT) has not been used in any systematic review before.The evidence provided in this review will be limited to low-middle-income countries.The exclusion of studies not published in English is a limitation for this review.
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Affiliation(s)
- Emmanuel Adebayo
- Adolescent Health Unit, Institute of Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Dongqing Wang
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Virginia, USA
| | - Adesola O. Olumide
- Adolescent Health Unit, Institute of Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
- University College Hospital, Ibadan, Nigeria
| | - Adesola Ogunniyi
- University College Hospital, Ibadan, Nigeria
- Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
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Doyle AM, Bandason T, Dauya E, McHugh G, Grundy C, Simms V, Chibanda D, Ferrand R. Common mental health and emotional and behavioural disorders among adolescents and young adults in Harare and Mashonaland East, Zimbabwe: a population-based prevalence study. BMJ Open 2023; 13:e065276. [PMID: 36918245 PMCID: PMC10016291 DOI: 10.1136/bmjopen-2022-065276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 12/21/2022] [Indexed: 03/16/2023] Open
Abstract
OBJECTIVES To estimate the prevalence of common mental health disorders (CMDs) and emotional and behavioural disorders among young people and to explore the correlates of CMDs risk. SETTING Five urban and periurban communities in Harare and Mashonaland East, Zimbabwe DESIGN: Population-based cross-sectional study PARTICIPANTS: Young people aged 13-24 years living in households in the study areas. OUTCOME MEASURES The primary outcome was the proportion of participants screening positive for probable CMDs defined as a Shona Symptoms Questionnaire (SSQ) score ≥8. Secondary outcomes were emotional and behavioural disorders measured using the Strength and Difficulties Questionnaire (SDQ), and adjusted ORs for factors associated with CMD. RESULTS Out of 634 young people, 37.4% (95% CI 33.0% to 42.0%) screened positive for probable CMDs, 9.8% (95% CI 7.5% to 12.7%) reported perceptual symptoms and 11.2% (95% CI 9.0% to 13.8%) reported suicidal ideation. Using UK norms to define normal, borderline and abnormal scores for each of the SDQ domains, a high proportion (15.8%) of Zimbabwean young people had abnormal scores for emotional symptoms and a low proportion had abnormal scores for hyperactivity/inattention scores (2.8%) and prosocial scores (7.1%). We created local cut-offs for the emotional symptoms, hyperactivity/attention and prosocial SDQ domains. The odds of probable CMDs increased with each year of age (OR 1.09, p<0.001) and was higher among those who were out of school and not working compared with those in school or working (adj. OR 1.67 (1.07, 2.62), p=0.04). One in five participants (22.1%) were referred immediately for further clinical assessment but uptake of referral services was low. CONCLUSIONS We observed a high prevalence of symptoms of CMDs among general population urban and peri-urban young people especially among those with no employment. There is a need for more accessible and acceptable youth-friendly mental health services.
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Affiliation(s)
- Aoife Margaret Doyle
- Medical Research Council International Statistics and Epidemiology Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- The Health Research Unit Zimbabwe (THRU ZIM), Biomedical Research and Training Institute, Harare, Zimbabwe
| | - T Bandason
- The Health Research Unit Zimbabwe (THRU ZIM), Biomedical Research and Training Institute, Harare, Zimbabwe
| | - E Dauya
- The Health Research Unit Zimbabwe (THRU ZIM), Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Grace McHugh
- The Health Research Unit Zimbabwe (THRU ZIM), Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Chris Grundy
- Medical Research Council International Statistics and Epidemiology Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Victoria Simms
- Medical Research Council International Statistics and Epidemiology Group, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- The Health Research Unit Zimbabwe (THRU ZIM), Biomedical Research and Training Institute, Harare, Zimbabwe
| | - D Chibanda
- Department of Psychiatry, College of Health Sciences University of Zimbabwe, Harare, Zimbabwe
- Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Rashida Ferrand
- The Health Research Unit Zimbabwe (THRU ZIM), Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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Addotey-Delove M, Scott RE, Mars M. Healthcare Workers' Perspectives of mHealth Adoption Factors in the Developing World: Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1244. [PMID: 36673995 PMCID: PMC9858911 DOI: 10.3390/ijerph20021244] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/22/2022] [Accepted: 12/29/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND mHealth applications provide health practitioners with platforms that enable disease management, facilitate drug adherence, facilitate drug adherence, speed up diagnosis, monitor outbreaks, take and transfer medical images, and provide advice. Many developing economies are investing more in mobile telecommunication infrastructure than in road transport and electric power generation. Despite this, mHealth has not seen widespread adoption by healthcare workers in the developing world. This study reports a scoping review of factors that impact the adoption of mHealth by healthcare workers in the developing world, and based on these findings, a framework is developed for enhancing mHealth adoption by healthcare workers in the developing world. METHODS A structured literature search was performed using PubMed and Scopus, supplemented by hand searching. The searches were restricted to articles in English during the period January 2009 to December 2019 and relevant to the developing world that addressed: mobile phone use by healthcare workers and identified factors impacting the adoption of mHealth implementations. All authors reviewed selected papers, with final inclusion by consensus. Data abstraction was performed by all authors. The results were used to develop the conceptual framework using inductive iterative content analysis. RESULTS AND DISCUSSION Of 919 articles, 181 met the inclusion criteria and, following a review of full papers, 85 reported factors that impact (promote or impede) healthcare worker adoption of mHealth applications. These factors were categorised into 18 themes and, after continued iterative review and discussion were reduced to 7 primary categories (engagement/funding, infrastructure, training/technical support, healthcare workers' mobile-cost/ownership, system utility, motivation/staffing, patients' mobile-cost/ownership), with 17 sub-categories. These were used to design the proposed framework. CONCLUSIONS Successful adoption of mHealth by healthcare workers in the developing world will depend on addressing the factors identified in the proposed framework. They must be assessed in each specific setting prior to mHealth implementation. Application of the proposed framework will help shape future policy and practice of mHealth implementation in the developing world and increase adoption by health workers.
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Affiliation(s)
- Michael Addotey-Delove
- Department of TeleHealth, School of Nursing & Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban 4041, South Africa
| | - Richard E. Scott
- Department of TeleHealth, School of Nursing & Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban 4041, South Africa
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Maurice Mars
- Department of TeleHealth, School of Nursing & Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban 4041, South Africa
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA 5042, Australia
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11
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Dambi J, Norman C, Doukani A, Potgieter S, Turner J, Musesengwa R, Verhey R, Chibanda D. A Digital Mental Health Intervention (Inuka) for Common Mental Health Disorders in Zimbabwean Adults in Response to the COVID-19 Pandemic: Feasibility and Acceptability Pilot Study. JMIR Ment Health 2022; 9:e37968. [PMID: 35960595 PMCID: PMC9555820 DOI: 10.2196/37968] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/27/2022] [Accepted: 08/06/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Common mental health disorders (CMDs) are leading causes of disability globally. The ongoing COVID-19 pandemic has further exacerbated the burden of CMDs. COVID-19 containment measures, including lockdowns, have disrupted access to in-person mental health care. It is therefore imperative to explore the utility of digital mental health interventions to bridge the treatment gap. Mobile health technologies are effective tools for increasing access to treatment at a lower cost. This study explores the utility of Inuka, a chat-based app hinged on the Friendship Bench problem-solving therapy intervention. The Inuka app offers double anonymity, and clients can book or cancel a session at their convenience. Inuka services can be accessed either through a mobile app or the web. OBJECTIVE We aimed to explore the feasibility of conducting a future clinical trial. Additionally, we evaluated the feasibility, acceptability, appropriateness, scalability, and preliminary effectiveness of Inuka. METHODS Data were collected using concurrent mixed methods. We used a pragmatic quasiexperimental design to compare the feasibility, acceptability, and preliminary clinical effectiveness of Inuka (experimental group) and WhatsApp chat-based counseling (control). Participants received 6 problem-solving therapy sessions delivered by lay counselors. A reduction in CMDs was the primary clinical outcome. The secondary outcomes were health-related quality of life (HRQoL), disability and functioning, and social support. Quantitative outcomes were analyzed using descriptive and bivariate statistics. Finally, we used administrative data and semistructured interviews to gather data on acceptability and feasibility; this was analyzed using thematic analysis. RESULTS Altogether, 258 participants were screened over 6 months, with 202 assessed for eligibility, and 176 participants were included in the study (recruitment ratio of 29 participants/month). The participants' mean age was 24.4 (SD 5.3) years, and most participants were female and had tertiary education. The mean daily smartphone usage was 8 (SD 3.5) hours. Eighty-three users signed up and completed at least one session. The average completion rate was 3 out of 4 sessions. Inuka was deemed feasible and acceptable in the local context, with connectivity challenges, app instability, expensive mobile data, and power outages cited as potential barriers to scale up. Generally, there was a decline in CMDs (F2,73=2.63; P=.08), depression (F2,73=7.67; P<.001), and anxiety (F2,73=2.95; P=.06) and a corresponding increase in HRQoL (F2,73=7.287; P<.001) in both groups. CONCLUSIONS Study outcomes showed that it is feasible to run a future large-scale randomized clinical trial (RCT) and lend support to the feasibility and acceptability of Inuka, including evidence of preliminary effectiveness. The app's double anonymity and structured support were the most salient features. There is a great need for iterative app updates before scaling up. Finally, a large-scale hybrid RCT with a longer follow-up to evaluate the clinical implementation and cost-effectiveness of the app is needed.
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Affiliation(s)
- Jermaine Dambi
- Rehabilitation Sciences Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe.,Friendship Bench, Harare, Zimbabwe
| | - Clara Norman
- Friendship Bench, Harare, Zimbabwe.,Research Support Centre, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Asmae Doukani
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Jean Turner
- Friendship Bench, Harare, Zimbabwe.,Research Support Centre, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | | | - Dixon Chibanda
- Friendship Bench, Harare, Zimbabwe.,Research Support Centre, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe.,Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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12
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Johnson AK, Enaholo O, Stranix-Chibanda L, Partridge SR. Editorial: mHealth Interventions for Improving Adolescent Sexual and Reproductive Health. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 4:945455. [PMID: 36303618 PMCID: PMC9580809 DOI: 10.3389/frph.2022.945455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/20/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Amy K. Johnson
- Feinberg School of Medicine, Northwestern University, Evanston, IL, United States
- Division of Adolescent Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- *Correspondence: Amy K. Johnson
| | - Ososese Enaholo
- Division of Adolescent Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
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13
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McCarthy OL, Mavodza C, Chikwari CD, Dauya E, Tembo M, Hlabangana P, Dembetembe R, Mpakami N, Bandason T, Free C, Smith C, Ferrand RA. Adapting an evidence-based contraceptive behavioural intervention delivered by mobile phone for young people in Zimbabwe. BMC Health Serv Res 2022; 22:106. [PMID: 35078457 PMCID: PMC8789333 DOI: 10.1186/s12913-022-07501-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the availability of a range of contraceptive methods, young people around the world still face barriers in accessing and using them. The use of digital technology for the delivery of health interventions has expanded rapidly. Intervention delivery by mobile phone can be a useful way to address young people's needs with regard to sexual and reproductive health, because the information can be digested at a time of the recipients' choosing. This study reports the adaptation of an evidence-based contraceptive behavioural intervention for young people in Zimbabwe. METHODS Focus group discussions and in depth interviews were used to evaluate the 'fit' of the existing intervention among young people in Harare, Zimbabwe. This involved determining how aligned the content of the existing intervention was to the knowledge and beliefs of young Zimbabweans plus identifying the most appropriate intervention deliver mode. The verbatim transcripts were analysed using a thematic analysis. The existing intervention was then adapted, tested and refined in subsequent focus group discussions and interviews with young people in Harare and Bulawayo. RESULTS Eleven key themes resulted from the discussions evaluating the fit of the intervention. While there were many similarities to the original study population, key differences were that young people in Zimbabwe had lower levels of personal and smart mobile phone ownership and lower literacy levels. Young people were enthusiastic about receiving information about side effects/side benefits of the methods. The iterative testing and refinement resulted in adapted intervention consisting of 97 messages for female recipients (94 for male), delivered over three months and offered in English, Shona and Ndebele. CONCLUSIONS Young people in Zimbabwe provided essential information for adapting the existing intervention. There was great support for the adapted intervention among the young people who took part in this study. The adapted intervention is now being implemented within an integrated community-based sexual and reproductive health service in Zimbabwe.
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Affiliation(s)
- Ona L McCarthy
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, England.
| | - Constancia Mavodza
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, England.,Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Chido Dziva Chikwari
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, England.,Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Ethel Dauya
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Mandikudza Tembo
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, England.,Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Portia Hlabangana
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Regedzai Dembetembe
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Nyasha Mpakami
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Tsitsi Bandason
- Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
| | - Caroline Free
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, England
| | - Chris Smith
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, England
| | - Rashida A Ferrand
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, England.,Biomedical Research and Training Institute, 10 Seagrave, Avondale, Harare, Zimbabwe
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Kharono B, Kaggiah A, Mugo C, Seeh D, Guthrie BL, Moreno M, John-Stewart G, Inwani I, Ronen K. Mobile technology access and use among youth in Nairobi, Kenya: implications for mobile health intervention design. Mhealth 2022; 8:7. [PMID: 35178438 PMCID: PMC8800198 DOI: 10.21037/mhealth-21-23] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 10/20/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Social media can be used to support the health of underserved youth beyond clinical settings. Young people are avid users of social media, but estimates of smartphone access among youth in sub-Saharan Africa are lacking, making it difficult to determine context-appropriateness of online and social media interventions. METHODS We conducted a cross-sectional observational survey assessing technology access and use among youth aged 14-24 receiving general outpatient or human immunodeficiency virus (HIV) care in three hospitals in Nairobi, Kenya. Correlates of smartphone access and social media use were evaluated by Poisson regression. RESULTS Of 600 youth, 301 were receiving general outpatient care and 299 HIV care. Median age was 18 years. Overall, 416 (69%) had access to a mobile phone and 288 (48%) to a smartphone. Of those with smartphones, 260 (90%) used social media. Smartphone access varied by facility (40% at the sub-county hospital vs. 55% at the national referral hospital, P=0.004) and was associated with older age [65% in 20-24-year-old vs. 37% in 14-19-year-old, adjusted prevalence ratio (aPR) 1.58, 95% CI: 1.30-1.92], secondary vs. primary education (aPR 2.59, 95% CI: 1.76-3.81), and HIV vs. general outpatient care (aPR 1.18, 95% CI: 1.01-1.38). Social media use was similarly associated with facility, older age, higher education, and male gender. CONCLUSIONS These data suggest that smartphone-based and social media interventions are accessible in Nairobi, Kenya, in the general population and youth living with HIV, and most appropriate for older youth. Intervention developers and policymakers should consider smartphone and social media interventions as candidates for youth health programs, while noting that heterogeneity of access between and within communities requires tailoring to the specific intervention context to avoid excluding the most vulnerable youth.
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Affiliation(s)
- Brenda Kharono
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Anne Kaggiah
- Department of Paediatrics and Child Health, Kenyatta National Hospital, Nairobi, Kenya
| | - Cyrus Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Paediatrics and Child Health, Kenyatta National Hospital, Nairobi, Kenya
| | - David Seeh
- Department of Paediatrics and Child Health, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Megan Moreno
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA
- Departments of Epidemiology, Medicine, Pediatrics, University of Washington, Seattle, WA, USA
| | - Irene Inwani
- Department of Paediatrics and Child Health, Kenyatta National Hospital, Nairobi, Kenya
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, WA, USA
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15
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Awopegba OE, Chukwudeh OS, Owolabi EO, Ajayi AI. Trends in emergency contraception awareness among women and girls in 28 sub-Saharan countries. BMC Public Health 2021; 21:1987. [PMID: 34732160 PMCID: PMC8567620 DOI: 10.1186/s12889-021-12067-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/21/2021] [Indexed: 11/23/2022] Open
Abstract
Background Studies have shown that emergency contraception (EC) remains underutilised in preventing unintended pregnancy in sub-Saharan Africa (SSA). Small-scale surveys have attributed EC underutilisation to gaps in EC awareness among SSA women and girls. However, limited studies have explored trends in EC awareness in SSA. We address this gap by examining trends in EC awareness using data from 28 SSA countries. Our analysis was disaggregated by age distribution, place of residence, level of education, and wealth to show differences in EC awareness trend. Methods We analysed the Demographic and Health Surveys (DHS) data of 1,030,029 women aged 15 to 49 on emergency contraception awareness. EC awareness was defined as having ever heard of special pills to prevent pregnancy within 3 days after unprotected sexual intercourse. Frequencies and percentages were used to summarise trends in EC awareness between years 2000 and 2019. Results Overall, there was an upward shift in the level of EC awareness in all countries, except in Burkina Faso, Niger, Chad, and Ethiopia. While some countries recorded a significant upward trend in EC awareness, others recorded just a slight increase. Women in Kenya, Ghana, Gabon, and Cameroon had the highest upward shift in EC awareness. For example, only 28% of women were aware of EC in Ghana in 2003, but in 2014, 64% of women knew about EC, an increase of over 36 percentage points. Increase in EC awareness was starker among women aged 20–24 years, those who resided in urban areas, had higher education, and belong to the highest wealth quintile, than those aged 15–19, in rural areas, with no formal education and belonging to the lowest wealth quintile. Conclusion Our analysis shows that the level of EC awareness has increased substantially in most SSA countries. However, EC awareness still differs widely within and between SSA countries. Intervention to improve EC awareness should focus on women aged 15 to 19, those with no formal education, residing in rural areas, and within the lowest quintile, especially, in countries such as Chad, Niger, Burkina Faso, and Ethiopia where level of EC is low with lagging progress. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-12067-y.
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Affiliation(s)
- Oluwafemi Emmanuel Awopegba
- Economics and Business Policy Department, Nigerian Institute of Social and Economic Research, Ibadan, Nigeria
| | - Okechukwu Stephen Chukwudeh
- Department of Criminology and Security Studies, Faculty of Social Sciences, Federal University, Oye-Ekiti, Nigeria
| | - Eyitayo Omolara Owolabi
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Anthony Idowu Ajayi
- Population Dynamics and Sexual and Reproductive Health, African Population and Health Research Centre, APHRC Campus, Manga Close, Nairobi, Kenya.
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