Contributions to the literature
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Many digital health interventions are developed globally. Fewer are evaluated and those that are and show a positive effect on health outcomes are not always implemented.
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Adapting evidence-base interventions for different contexts is a financially and time efficient way to expediate the delivery of effective interventions to the people that need them.
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This intervention adaptation study demonstrates that intervention adaptation can be done rigorously and in a relatively short amount of time, despite unanticipated disruptions caused by the COVID-19 pandemic.
Background
Methods
Evaluating the fit of the existing intervention
Analysis of the initial FGDs and IDIs
Desk-based adaptation
Testing and refining the content
Results
Evaluating the fit of the existing intervention
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Theme 1: Personal mobile phone ownership and smart phone ownership is not universal. Many participants reported that they did not own a personal mobile phone but most had access to one (e.g. they shared a family member’s). Some participants did not have access to a ‘smart phone’ (a mobile phone that has advance technical functionality such as Internet access, data storage and email capability).
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Theme 2: Contraception information delivered to your mobile phone is convenient. Participants spoke about the convenience of receiving contraceptive information on the phone; young people sometimes do not have time to visit the clinic and receiving information on their phone means that they do not have to travel far distances to the clinic for it. They talked about the ‘stress of walking long journeys’ to the clinic and the 'burden of travelling'. Other conveniences mentioned were that the information can be shared with others and read at a time of their choosing. There was a lot of enthusiasm for learning and gaining knowledge through SMS—participants appreciated that receiving knowledge through this mode is a good way to learn. One participant was enthusiastic about reading the information on the phone because they would not have to deal with feeling 'shy' with a face-to-face discussion with an adult. Others spoke about being 'afraid' and 'ashamed' to ask adults about contraception face-to-face and noted that receiving information on their phone is a convenient way around this.“It is a good idea to receive this information on your phone because you are able to read it on your own at your convenience “ (Theme 2, FGD-01-male)
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Theme 3: SMS is the most accessible delivery mode. There was almost universal preference for SMS as the mobile intervention delivery mode, which was primarily based on financial factors. Participants preferred SMS because they are cheap—receiving messages through WhatsApp (the predominant instant-messaging application in Zimbabwe) requires the user to purchase data bundles, whereas SMS can be received anytime. In addition, participants sometimes they did not have access to a phone that can support WhatsApp.“Text messages are more appropriate since every cell phone has access to text messages and also it is easy to get information as compared to WhatsApp and internet where one has to buy data to have access to the messages.” (Theme 3, IDI-02-male)
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Theme 4: Young people have varying levels of knowledge about contraception. The implant, intra-uterine device (IUD ‘loop’), oral contraceptives, injection, emergency contraception and condoms were widely known among participants. However, few participants seemed to have a deeper knowledge about how the methods are actually used or how they work.“I don’t understand much, all l know is that it’s inserted in the uterus.” (Theme 4, IDI-02-female)
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Theme 5: Young people hold negative views about contraception. Participants expressed a range of negative views about contraception. The most common concern was contraception’s perceived effect on fertility after discontinuation, with participants specifically mentioning the implant (referred to by the brand name commonly available, ‘Jadelle’), oral contraceptives and injections as causing infertility or problems with conceiving. Participants felt that condoms were better because they do not affect fertility and that long acting methods were not good for the newly married and more appropriate for after childbearing. Participants also expressed concerns regarding the side effects of the implant, particularly prolonged bleeding, causing men to ‘run away’. Some participants heard that men can feel the IUD and that it ‘stores dirt’ and causes it to accumulate in the uterus. There was further anxiety around the expiration date of Jadelle, with participants expressing uncertainty around how long it is effective for. A Jadelle inserted that is ‘about to expire’ could cause an unintended pregnancy and could prevent a planned pregnancy if you get married before it has expired. One participant had heard that contraception could cause uterine cancer. Another view was that if women used emergency contraception frequently, it would become ineffective.
“For boys its common for them to use condoms but it’s not common for young girls to be using contraceptives because we were told that it is not good for girls to take contraceptives before they have children it will affect their fertility.” (Theme 5, FGD-01-male)
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Theme 6: Young people use and value condoms but are not confident using them. Participants spoke about how common condom use is among young people, however some are ‘shy’ to purchase them. They also spoke about how they lacked confidence in using them successfully, saying that they needed more knowledge about how to use them without having them burst. Participants talked about how condom use within marriage could cause relationship conflicts. One male participant mentioned that some women do not agree with using condoms with their partners because they feel that condoms are meant for sex workers. There were no major differences in views between male and female participants.“Most youths use condoms but they do not have enough knowledge in terms of how to wear the condoms. They do not know the proper way of putting it on and in most cases its done in rush.” (Theme 6, FGD-02-male)
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Theme 7: It is very easy to become infected with HIV though sex without a condom. Sex without a condom was viewed as very risky with regard to HIV infection. Many participants also mentioned not knowing their partners’ status.“It is very easy because if my partner has STIs and am not aware of it, so they are high chances of me getting HIV.” (Theme 7, FGD-01-female)
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Theme 8: Joint contraception decision making, communication, and use is difficult within marriage. Participants spoke about how married women are valued for being a mother, and society and the wider family expect this role will follow shortly after marriage. Because contraceptive use within marriage revolves around whether the couple already have a child, participants thought that joint decision making is not an accepted concept and use is difficult. A male interviewee also mentioned that it is not acceptable for women to use contraception if they have not given birth.“I don’t give my own decisions. My husband does.” (Theme 8, FGD-02-female)“That’s difficult, because, when we get married we want to have a family, and when the woman refuses to have children, the man wonders, why he got married. That is when a husband will make a decision to have a small house (he chuckles),” (Theme 8, IDI-01-male)
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Theme 9: Confidence in talking about contraception varies, but most do not feel confident talking to partners or providers. Young people mentioned that some women are afraid to talk to their husbands about contraception, particularly if they are a lot younger, and that the husband has the authority to make decisions about contraception. Some young male participants, however, thought that young men and women are confident talking to partners. Others thought it depends on how close you are with your partner. In clinics, young people do not have confidence talking to providers because they think that providers will tell them that they are too young to use contraception (if they are under 18). Participants mentioned choosing to collect condoms at the clinic when no one is watching, out of fear that clinic staff will think negatively of them (primarily among unmarried young people).“If we ask, they [providers] will tell us that you have not reached the age of getting contraceptives which 18 years not 16 years hence by this it reduces our confidence level to ask anything.“ (Theme 9, FGD-01-female)“I don’t even have that confidence even to get the condom from my pocket to use it, it’s difficult to talk to your partner because you don’t know how she will react to it.” (Theme 9, FGD-02-male)
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Theme 10: Young women fear trying new methods. Young women spoke about the ‘fear’ around how their body would respond to a contraceptive method they have not used before. They thought that hearing about other women’s experiences in trying contraceptive methods they have never tried before would help them feel more confident.“It’s scary because I want to know whether it’s going to be accepted by my body or might get side effects so it’s scary to change” (Theme 10, FGD-02-female)
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Theme 11: Preferences for intervention content. Regarding intervention content, participants wanted information on condom use and contraception, ‘testimonies’, how contraception works and side effects/benefits of contraception. They preferred one to three short messages a day offered in Shona and English.“I want to receive everything.” (Theme 11, FGD-02-female)“I think at least three messages, maybe in the morning, in the afternoon and in the evening.” (Theme 11, IDI-01-male)
Desk-based adaptation
Similarities to the existing intervention
Differences from the existing intervention
Summary of adaptations
Testing and refining the content
Round 1
“What is the reason for having many contraceptive methods which work differently? I really want an explanation on that to understand why the methods are many but work differently… Isn’t there another method that we can use other than condoms?” (Round 1-IDI-male-Harare)“As for me I feel great opening such messages and if you are to send the messages to me I will open them freely because I want to learn.” (Round 1-IDI-male-Harare)
Round 2
“I think the messages were coming from someone who really wants us as the youth to know about pregnancy and contraceptives since this is something good. So wherever this person is, they really did a great job in writing the messages and trying to make us young people understand our health systems and take care of ourselves in the process as well” (Round 2-IDI-male-Harare)“Well I think it quite useful to have such knowledge, but maybe the challenge might come when one is dealing with a partner who does not want to discuss such matters so it might be difficult to talk to my partner about the issue of contraceptives. However, the information is very useful especially when you get one whose willing to talk about such matters.” (Round 2-IDI-female-Bulawayo)
Round 3
“Maybe the messages can be sent at intervals for instance saying that at 10 a.m a Shona message is sent then at 11 a.m an English message is sent. So someone will get to choose which message they want to read so 2 messages mixed with both Shona and English will do” (Round 3-FGD-female-Harare)“I want to tell the truth honestly if I see a message that says something health related and with a salutation signature written “CHIEDZA” I will definitely read it because I will also remember that it is the same CHIEDZA that assisted me with free pads and condoms so yes definitely if it comes from CHIEDZA I will read it .” (Round 3-FGD-female-Harare)