We purpose to develop a mobile phone application (app) to increase awareness and uptake of sexual and reproductive health (SRH) services among youth aged 18 to 30 years in Uganda. This app is intended to link users to health facilities where they can access SRH goods and services. It will also reduce on the challenge of poor access to SRH services due to lack of privacy and confidentiality: the app allows users to make orders online and goods are delivered to pick up points of individuals’ choice. We will partner with an app developer to develop the app. We will then pilot this study among students of Kyambogo university, and participants who will download the app will be followed up at 1, 3 and 6 months. We will collect data on app usage from the server, and perform analyses to determine technical performance, impact (increase in SRH demand and usage), acceptability, usability, and cost effectiveness. The prototype app includes an advertising interface to enable corporations and other business entities to collaborate as potential advertisers and to generate revenue for sustainability. If successful, we propose to extend the program to all the youth in the country who own a smart phone but, also, include other services.
Background
Across the globe, youth account for 17.6% of the population size, and in low and middle-income countries (LMICs), while 90% are aged between 10 and 24 years [
1]. During adolescence, many young women are at high risk of teen pregnancies, unsafe abortions and as a consequence, maternal and child mortality. Across the globe, over 16 million girls aged 15 to 19 give birth annually [
2,
3] and over seven million girls aged 10 to 19 get unintended pregnancies for reasons such as poor access to education and contraception services [
2,
4,
5]. These pregnancies lead to over three million unsafe abortions accounting for the largest cause of mortality among women aged 15 to 19 [
2]. Of the available sexual and reproductive health (SRH) interventions, the use of modern contraception alone has the potential to prevent approximately 30% of maternal and 10% of child deaths [
6]. In addition to preventing the adverse health effects of unintended pregnancies, contraceptive use contributes to the realization of Sustainable Development Goals (SDGs) by limiting the number of unplanned births and child deaths, and increasing the resource envelope that families spend on other necessities using money saved by having planned pregnancies [
7].
In Uganda, youth face many SRH risks such as the unmet need for contraception (30%), which leads to unplanned pregnancies (43%) that result in unsafe abortions (30%) and sexually transmitted infections (17%) [
8], [
9]. The majority of the youth in the country also experience unemployment (62%), engagement in risky sexual behavior (56%), possession of limited knowledge of SRH services (39%) and limited access to SRH services (22%) [
10‐
13].
Awareness and uptake of SRH services remains sub-optimal in LMICs [
2,
12,
14], and challenges to the provision of SRH services include lack of privacy and confidentiality, knowledge gaps, lack of finances, cultural and social stigma, biased service providers towards the youth, and inconvenience in accessing SRH services despite their availability [
15‐
18]. Although there have been improvements in creating a youth-attractive environment for SRH services and access to tools, more work is needed [
19].
The question researchers and policymakers should be asking is, what works for the youth? Earlier reviews suggest that SRH interventions targeting youth should be accessible, equitable, appropriate and effective [
17]. In our understanding, and in the context of Uganda, the challenges to reaching the current generation of poor and young adolescents are mostly related to privacy, confidentiality, and limited SRH knowledge [
11].
What strategies are currently in place to improve access to SRH services and tools? A largely successful strategy involved SRH public media campaigns (e.g., through radios, billboards, local skits, television campaigns), while sensitizing the youth [
20‐
22]. Leveraging the high penetration of mobile technology would be a great deal since 27% of phone users are aged under 30 [
22,
23], and in Uganda, it’s estimated that 37% of the country’s population has access to the internet [
24]. This serves as a potential solution through the provision of high-quality, non-judgmental and non-stigmatizing SRH services.
Is there a role for mobile phone applications to increase SRH access and uptake? It certainly seems smart and possible to leverage the high mobile phone coverage rates to increase SRH services uptake. The literature is replete with evidence that
text messaging interventions may induce both short and long-term behavioral change, and improve outcomes related to smoking cessation [
25,
26], physical activity and obesity [
13‐
19], diabetes, asthma self-management, adherence to hypertension medication and SRH [
27‐
34]. This is because many people can access text messages despite having different types of phones.
Several programs are being implemented around the world that integrate mobile technology to improve SRH uptake among youth, and deliver SRH information, and have been proven to be cost-effective in Kenya and Tanzania [
32,
35]. Confidentiality and provision of information that is easy to understand increased demand for family planning information using mobile phones [
16,
35]. While several mobile SRH applications exist, most lack sufficient functionality, usability, and effectiveness, measured as long-term, sustainable behavioral change [
17,
30,
36].
In a review of the literature, we found some mobile phone apps for SRH [
30], a competition and process to develop an SRH application [
27] and other projects to develop SRH apps for at-risk youth in LMICs [
30]. Despite the high level of SRH information consumption via mobile phone applications, evidence of successful use of SRH mobile phone applications in Uganda is limited, and applications that can increase uptake of SRH services and tools are non-existent.
In this study, we propose to develop a mobile phone-based sexual and reproductive health services awareness and delivery application with the objective of increasing the demand for SRH services amongst the youth in Uganda. Our proposed innovation bridges the privacy and confidentiality gap by allowing users to make orders online using the application and have them completed and delivered to their preferred pick-up points. Using the application, users will also be able to schedule a visit to any of the partner clinics. The proposed innovation will reduce both the knowledge and financial barriers to access of SRH information and services by providing comprehensive SRH information and subsidizing SRH services. In the long run, the SRH App will be self-sustaining through revenues from in-app advertisements.
The concept of using mobile apps to link users to services, make orders online, and have orders delivered is itself not novel. Mobile apps like Uber [
37] for car services, SafeBoda [
38] for boda-boda services, and Jumia [
39] for shopping and food deliveries have attracted huge demand from the public. We propose to leverage this service delivery model but with a key difference: instead of users paying for services, we propose to test a model of revenue generation that us dependent on in-app advertising. Some marketers argue that in-app advertising offers users a good experience, especially if highly tolerable and likable ads are designed [
39].
In this protocol, we describe a pilot study to develop and evaluate a mobile phone application (app) aimed at increasing uptake of SRH services among the youth in Uganda. We anticipate that this study will lead to the development of a demand-driven, culturally-relevant, and easy-to-use mobile app to enhance the uptake of SRH services among the youth in Uganda and beyond. In addition to reducing the financial and knowledge gap in SRH services, the app that is planned for development and pilot testing in this study is unique in three ways: 1) it will be developed in a collective process that involves local stakeholders and the target population in the design process to ensure high acceptability and user satisfaction, 2) it bridges the gap of privacy and confidentiality by allowing users to anonymously make orders online, and have them delivered at their preferred pick up points and also allows users to choose a visit to a preferred clinic, and 3) it will have an advertisers interface to generate revenue to sustain SRH service subsidies. The objectives of this study are to 1) develop a mobile phone-based app to increase awareness and uptake of SRH services among the youth aged 18 to 30 years in Uganda, 2) assess the effectiveness of the app on SRH uptake and awareness among the youth aged 18 to 30 years in Uganda, 3) determine the acceptability and usability of the app among the youth aged 18 to 30 years in Uganda, 4) assess the cost-effectiveness and budget impact of the app services delivery model from the perspective of the Ugandan government and taxpayer, and 5) pilot test in-app advertising as a way of generating revenues to sustain the SRH service subsidies associated with the app.