Slow and steady, it’s not a race: Building the evidence base for digital self-care 

Sarah Brittingham, Senior Technical Officer, FHI 360

Step on to any city street, and you are likely to spot heads bent at that characteristic angle, deep in conversation with smartphones. The degraded human interaction so palpable in the image below visualizes the distance we feel from our fellow humans when we are immersed in our private digital worlds. But there’s another side to that coin – the rapid expansion of digital technology holds promise for many.  

Photo by Pelle Cass

Digital self-care is gaining momentum across many sectors. In the health sector, digital self-care platforms offer important advantages, including enhanced privacy, greater reliability of information, and reduced cost related to obtaining health information.   

Theory of change from Digital Health for Social and Behavior Change High Impact Practices Brief

Where family planning (FP) is concerned, women, men and young people who do not want to become pregnant but are not using contraception can utilize digital self-care platforms discreetly to expand their knowledge about family planning methods, counter misconceptions, and access services. These platforms can contribute to shifting two key behavioral outcomes: increasing use of family planning and correct and consistent use of contraceptive methods. 

In this blog post, we’ll describe the state of the evidence base for social and behavior change digital interventions that aim to support users of family planning, detail challenges related to research design that have led to evidence gaps, and share how FHI 360’s Research for Scalable Solutions, a global, USAID-funded implementation science project focused on FP, is poised to move the needle with four different studies that represent distinct LMIC-based implementation experiences of the below theory of change.  

The evidence and the challenges 

Early evidence about digital health for social and behavior change (SBC), or the use of digital technologies to support, maintain, and adopt healthy sexual and reproductive health behaviors (we’ll call it digital self-care for short), showed that text and voice-based platforms (SMS & IVR), can indeed teach people about family planning (FP).  

Image from m4RH, FHI 360’s SMS-based digital self-care

But evidence is limited for digital self-care’s ability to increase adoption of FP methods and continuation. And studying digital interventions is not simple, for several reasons: 

  • Digital health is often part of a constellation of interventions, so it can be difficult to isolate the effects. As a result, there are few gold standard (RCT) studies out there for digital SBC interventions.  
  • Often, study participants are recruited virtually, and can therefore have greater attrition.  
  • And engagement with digital platforms is variable, making it difficult to meaningfully understand efficacy.  
  • In addition, the technology these tools leverage is rapidly evolving, so it is difficult for the evidence to keep up.  

For example, many young people now turn to social media, websites, and even chatbots to learn about their contraceptive options, get individualized recommendations or referrals, purchase methods, and get follow-up support. And in some locations, drones deliver contraceptives directly to users.  

Given these challenges, it isn’t surprising that there are quite a few questions that are not fully answered in the world of digital health for social and behavior change. For example: How well do these interventions work? Who uses them and where? Who is left behind? Can these technologies effectively support people to not only increase their knowledge about contraceptives, but also to help them adopt a method and use it correctly, consistently, and until they no longer need or want to prevent pregnancy? How can digital technologies contribute to renewed interest and momentum around self-care (defined by WHO as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a health-care provider”)?   

Researchers working under the R4S project are trying to find out. We have set out to contribute to the digital self-care knowledge base in three concrete ways: 1) improve the quality and design of digital FP self-care interventions; 2) produce evidence about what works and why to inform implementation and scale; and 3) build consensus around methods and measures for research on digital FP self-care. To select which digital self-care for FP platforms to study, we first considered them based on how they aim to serve users – by providing general information, tailored information, tools or assessments, or links to services (see below framework). We then developed a set of research questions to hone in on emerging themes:  

  • How do users feel about interacting with the platforms? (we’ll call this acceptability/feasibility),  
  • How do users interact with the platforms? (think user journey/experience),  
  • Do the platforms work? (we’ll measure proximal outcomes like knowledge, self-efficacy, reproductive empowerment, as well as effect on uptake and continuation of contraceptive use).  
  • How much do they cost?  

To expand evidence on digital platforms making use of newer technologies in real-world conditions, we decided to partner with askNivi in India, Ylabs’ CyberRwanda in Rwanda and PSI’s Counseling for Choice in Cote d’Ivoire. Each study tackles questions related to digital self-care for family planning from a unique vantage point.  

The AskNivi chatbot provides sexual and reproductive health information, screenings, and referrals to products and services in the public and private sectors to users across Kenya, Nigeria, South Africa and India. By increasing knowledge about fertility, contraceptive methods, and where one can obtain them, askNivi can increase uptake and ultimately, continuation, as askNivi also provides tailored follow-up support. Our study, which is taking place in Madhya Pradesh, India, uses a randomized encouragement design to assess the impact of askNivi on contraceptive uptake, with additional mixed-method study components building an understanding of the role of askNivi in continuation, an outcome with limited evidence. It will also offer information to speak to the perennially important question of the cost of the intervention per each FP adopter (the environment section of R4S’ framework pictured in light blue above).  

Messages from AskNivi offer information about FP and more

The AskNivi chatbot provides sexual and reproductive health information, screenings, and referrals to products and services in the public and private sectors to users across Kenya, Nigeria, South Africa and India. By increasing knowledge about fertility, contraceptive methods, and where one can obtain them, askNivi can increase uptake and ultimately, continuation, as askNivi also provides tailored follow-up support. Our study, which is taking place in Madhya Pradesh, India, uses a randomized encouragement design to assess the impact of askNivi on contraceptive uptake, with additional mixed-method study components building an understanding of the role of askNivi in continuation, an outcome with limited evidence. It will also offer information to speak to the perennially important question of the cost of the intervention per each FP adopter (the environment section of R4S’ framework pictured in light blue above).  

Messages from AskNivi offer information about FP and more.

By providing digital access to RH/FP information via storytelling and direct links to local youth-friendly services, CyberRwanda has three primary objectives: to increase FP uptake, delay initiation of childbearing, and increase rates of HIV testing among Rwandan adolescents ages 12-19.  How? CyberRwanda is designed to increase knowledge, attitudes, perceived social norms, and perceived behavioral control. The intervention leverages the benefits of delivering intervention content digitally (there’s a native app and a website), including increased privacy and confidentiality, while addressing the digital divide by providing the intervention through school- or youth center-based tablets that can be accessed by adolescents who might not otherwise have access to digital technologies. Our study is focused on youth center implementation, complementing a separate RCT of the school-based model. We use a serial cross-sectional design to assess the intervention’s effects on relevant behavioral outcomes, including intent to use a modern method, perceived norms, and knowledge related to fertility awareness and contraceptive methods. The study will also generate evidence about the potential for financial sustainability from CyberRwanda user, implementer, and stakeholder perspectives. Ultimately, this multi-faceted evidence can guide decisions about future implementation and scale-up. 

CyberRwanda’s comic teaches youth about dual protection.

Counseling for Choice is a chatbot implemented by PSI in Benin, Malawi, and Cote d’Ivoire. By engaging users in a conversation about their preferences and needs in terms of FP methods, it aims to increase knowledge and service utilization, ultimately leading to increased method satisfaction and continuation. Who will interact with the chatbot? How will they find it? What will they think and do? Our Counseling for Choice study uses a descriptive, mixed method design using surveys, back-end data, and qualitative interviews to explore the user population based in Côte d’Ivoire and their experiences, including insight into female users’ perceptions of how engaging with the tool affects their FP-related self-efficacy and their subsequent FP-related intentions and actions, including whether they adopted a method. Our learnings will inform future iterations of the tool to better meet the needs/preferences of users and can serve as a model for maximizing the use of data generated through digital self-care interventions.

Gabi, modeled after an Ivorian nurse, offers a personalized experience, including recommended contraceptive methods based on user’s responses to a set of questions.

We are exploring the possibility of a fourth study in digital self-care for family planning to complement anticipated contributions to the evidence base. In the coming months, we seek to identify a digital self-care platform that uses different or additional technology (beyond chatbots or websites) so that we can focus in on questions of how people navigate those different components. 

Looking ahead 

We look forward to each study’s contributions to the evidence base for digital self-care for FP AND for the opportunity to inform further replication and or expanded implementation of these and other digital self-care interventions. Each study will be broadly disseminated in the countries in which they were conducted and globally to help promote greater uptake of the results and to advance thinking on appropriate methods and measures for research on digital platforms.  

We know we there are others who are working diligently to advance the evidence in digital self-care. To support our digital health community to be better informed, coordinated, and aligned as we each contribute to building evidence, we hope to convene those currently conducting research on digital self-care for FP in 2023 to document what evidence is coming down the pipeline, determine what gaps remain so as to help direct future research, and share best practices relating to research design and methods. Interested? Please sign up for a distribution list by emailing, R4Sinfo@fhi360.org.

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