Effect of a Digital School-based Intervention on Adolescent Family Planning and Reproductive Health in Rwanda: A Cluster-randomized Trial

"The results advance knowledge on youth sexual behavior and the utility of digital tools with and without in-person facilitation to improve knowledge, attitudes, self-efficacy and behavior during a critical and sensitive development stage of adolescence."

Harmful gender norms and lack of access to high-quality family planning and reproductive health (FP/RH) information, services, and products prevent many young people from completing school HIV-free and avoiding unintended pregnancy. Digital health interventions are a promising approach for improving adolescent FP/RH outcomes in low-resource settings by mitigating health misinformation and extending quality healthcare coverage. This cluster-randomised hybrid effectiveness-implementation study evaluates CyberRwanda, a digital FP/RH intervention for Rwandan adolescents. 

As detailed at Related Summaries, below, CyberRwanda was developed using a multiyear, participatory, human-centred design (HCD) process to address gaps in FP/RH care in Rwanda. It was designed as an online platform with the following three main features: (i) STORIES: webcomics on navigating relationships and sex (including sexual consent, contraceptive use, adolescent pregnancy, and HIV/sexually transmitted infections); (ii) LEARN: informational guides, videos, audio recordings, and frequently asked questions focused on menstruation, puberty, gender equality, relationships, consent, education, careers, money, and goal setting; and (iii) SHOP: a direct-to-consumer online store for discreet ordering of health products (for example, condoms, emergency contraception, oral contraception, pads, and paracetamol) from nearby pharmacies, health posts, and health facilities trained in youth-friendly services. The platform also included a facility finder to assist adolescents in finding nearby health facilities.

CyberRwanda was implemented in schools and youth centres; however, the present study evaluated school-based implementation only. Schools received one of two implementation models: self-service (self-guided access to the CyberRwanda platform on tablets provided to schools, school computers or personal devices) or facilitated (self-guided and group access to the CyberRwanda platform along with peer-led weekly clubs to reinforce its content).

Sixty schools were randomised 1:1:1 to control or to one of the two implementation models (self-service or facilitated). Eligible participants were aged 12-19 years, in secondary school levels 1 or 2, and willing to provide consent or assent/parental consent and contact information for follow-up. In 2021, 6,078 randomly selected adolescents were enrolled. At 24 months, 91.3% of participants were retained and included in the primary intention-to-treat analyses (control, n = 1,845; self-service, n = 1,849 and facilitated, n = 1,858).

CyberRwanda was perceived favourably and widely accessed by students in participating schools. However, the majority of the study population reported they were not yet sexually active, and the researchers did not find significant impacts of CyberRwanda on the primary outcomes of modern contraceptive use and childbearing among all female adolescents and HIV testing in the full sample. However, significantly higher modern contraceptive use was observed in the CyberRwanda facilitated arm in a prespecified analysis of sexually active participants. Specifically, sexually active participants in facilitated schools were significantly more likely to report having ever used a condom compared to those in control (61.9% versus 53.3%; prevalence ratio (PR) = 1.19, 95% confidence interval (CI) = 1.05-1.35). Sexually active participants in the combined CyberRwanda arm and the facilitated arm were also significantly more likely to report discussing contraception with their most recent sexual partner (facilitated versus control = 59.5% versus 52.9%, PR = 1.15, 95% CI = 1.03-1.30). These findings suggest that longer-term evaluation is needed to examine effects as more of the study population becomes sexually active and has increased demand for contraception.

The facilitated implementation model demonstrated stronger benefits on FP/RH-related attitudes and behaviours among adolescents compared to the self-service model. However, in most cases, the width of the CIs could not rule out that the two models performed similarly. The researchers hypothesise that the in-person element and group setting of the facilitated model (that is, peer-led club sessions that reached large numbers of students) may be important to foster deeper engagement with the digital content, increase exposure to sexual health education, and ultimately influence FP/RH behaviour. Still, it remains uncertain as to whether these potential benefits are strong enough to warrant the added complexity and costs of the facilitated model compared to self-service.

Despite nearly two-thirds of participants reporting that CyberRwanda's direct-to-consumer SHOP feature made it easier for them to purchase health products, SHOP orders were unexpectedly infrequent. While supply-side challenges may have deterred SHOP use, the most common explanation provided by participants was that they did not need or want any products. This lower-than-expected demand for contraceptives may relate to the low prevalence and frequency of sexual activity among the cohort.

The researchers conclude that, although the CyberRwanda intervention did not substantially impact the primary outcomes, the positive impacts they observed on contraceptive use among sexually active participants and on intermediate outcomes in the full sample suggest that CyberRwanda is working as intended. They anticipate that "early exposure to the platform's youth-friendly, age-appropriate FP/RH information for adolescents who are not yet sexually active may improve outcomes when they engage in sexual behavior in the future."

Full list of authors, with institutional affiliations: Rebecca Hémono, University of California, Berkeley, School of Public Health; Emmyson Gatare, YLabs Rwanda; Laetitia Kayitesi, YLabs Rwanda; Lauren A. Hunter, University of California, Berkeley, School of Public Health; Laura Packel, University of California, Berkeley, School of Public Health; Nicole Ippoliti, YLabs USA; Diego Cerecero-García, Imperial College London, School of Public Health; David Contreras-Loya, Tecnologico de Monterrey; Paola Gadsden, Health Research Consortium (CISIDAT); Sergio Bautista-Arredondo, National Institute of Public Health (INSP), Cuernavaca, Mexico; Felix Sayinzoga; YLabs Rwanda; Michael Mugisha, University of Rwanda; Stefano M. Bertozzi, University of California, Berkeley, School of Public Health, INSP (Cuernavaca, Mexico), University of Washington; Rebecca Hope, YLabs USA; Sandra I. McCoy, University of California, Berkeley, School of Public Health