The effectiveness of digital sexual health interventions for young adults: a systematic literature review (2010-2020)

Digital Sexual Health Education for Young Adults (18-35 Years): A Scoping Review Protocol

Background and Aims

Young adults is a key stage for sexual development. Digital interventions provide innovative ways to deliver sexual health education to young adults. This scoping review protocol outlines a plan to map the existing literature on digital sexual health education (DSHE) for young adults, focusing on the dimensions and characteristics of these interventions.

Methods

This scoping review will adhere to a comprehensive 14-step methodological framework, integrating the established Arksey and O'Malley methodology with enhancements by Tricco and Peters. This review will follow the PRISMA-ScR guidelines. The study selection process adhered to the PICOS framework. A combination of thesauri and free-text methods will be employed. Keywords within each concept were connected using the Boolean operator "OR," whereas different concepts were linked using the operator "AND." Databases such as Web of Science (ISI), PubMed, Scopus, EMBASE, and the Cochrane Library (CDSR, Central) and search engines such as Google Scholar and Elmnet were utilized. The extracted data will be synthesized and presented using diagrams and tables accompanied by a narrative summary.

Discussion

This scoping review will provide a valuable synthesis of the current state of DSHE for young adults. The findings are intended to inform the development and implementation of effective DSHE programs by researchers, educators, policymakers, and healthcare providers. Ultimately, this study contributes to a broader effort to improve the sexual health of young adults.

Ethical Code

IR.SHMU.REC.1403.085.

'We Are Trying to Make Sense of Our Lives': Health Promotion in the Context of Young People's Digital Sexual Environment

ISSUE ADDRESSED

Young people's engagement with sexual content online has received ongoing attention in both policy and practice. However, there remains limited understanding of how health promoters can best engage with digital environments to support young people's learning about sex and relationships in the context of their existing digital practices.

METHODS

Qualitative, in-depth interviews were conducted with 22 young people aged 18-25 and 22 key informants specialising in relationships and sexuality education (RSE), sexual health and digital content design.

RESULTS

Young people interact with digital sexual health content from a wide range of sources and platforms. This environment serves as an important space for self-exploration in relation to sex, relationships and identity that is situated in the broader context of young people's offline environment, community, and friendships.

CONCLUSIONS

Digital spaces support young people to develop skills and knowledge about sex, relationships and identity by providing access to diverse resources across various platforms and communication modes. Having a range of information and perspectives online enables young people to exercise their judgement, critically reflect and build their skills and knowledge in important ways. SO WHAT?: To support young people's sexual health, it is necessary to understand the key elements of online engagement that help young people in building an understanding of sex and relationships. This includes an understanding of online health promotion as contributing to existing formal and informal sexual health messaging.

A Digital Pornography Education Prototype Co-Designed With Young People: Formative Evaluation

Background

Interventions to help young people make sense of sex and relationships in the context of widely available pornography are becoming increasingly supported in school settings. However, young people who experience disruptions to their education often have less access to such programs. Digital platforms may offer a more accessible method to deliver tailored sexual health and pornography literacy to young people who are disengaged from mainstream schooling, or who experience other types of structural disadvantage.

Objective

This study aimed to describe the formative evaluation of "The Gist" a co-designed online sexual health education and pornography literacy prototype designed to meet the sexual health information needs of structurally marginalized young people in Australia.

Methods

We conducted iterative workshops with 33 young people aged between 15 and 24 years recruited from an alternative education school in Melbourne, Australia. Through interactive activities, participants evaluated the overall prototype design, including its usability, desirability, inclusiveness, and potential for impact.

Results

Participants reported The Gist to be easy to use (17/20, 85%) and safe (19/23, 83%), with "hot" branding (25/30, 83%). However, perceived content relevance was dependent on the participants' existing level of sexual health knowledge and experience, with only 31% (7/23) agreeing that "The Gist feels like it was made for me." The interactive learning activities such as the debunked (myth-busting) and quiz features were among the most used and well-liked on The Gist platform. Low unprompted engagement with the prototype outside of facilitated workshop settings also confirmed previous researcher postulations that The Gist as a standalone digital platform is unlikely to meet the needs of this population group. Further design refinements are needed to improve user experience, including more interactive activities and visual information in place of heavily text-based features.

Conclusions

This study provides important insights into the design and sexual health information needs of structurally marginalized young people. Further research is needed to assess the overall efficacy of The Gist prototype, as well as its ability to positively influence young people's sexual attitudes, beliefs, and behaviors. Future iterations should consider hybrid or face-to-face delivery models to better capture student engagement.

The behavioural and cognitive impacts of digital educational interventions in the emergency department: A systematic review

Ensuring patients and their caregivers understand the health information they receive is an important part of every clinical visit. Digital educational interventions like video discharge instructions, follow-up text messaging, or interactive web-based modules (WBMs) have the potential to improve information retention and influence behaviour. This study aims to systematically evaluate the impact of these interventions on patient and caregiver cognition and behaviour, as well as identify the characteristics of successful interventions and observe how success is measured. In December of 2022, a systematic literature search was conducted in several databases (Cochrane, Embase, MEDLINE (Ovid), Web of Science, ClinicalTrials.gov, and Google Scholar) for randomized controlled trials (RCTs) published between 2012 and 2022. In 2024, an identical search was performed for articled published between 2022 and 2024. Studies testing patient- and caregiver-facing digital educational interventions in the emergency department for behavioural and cognitive outcomes were included. Data from 35 eligible studies encompassing 12,410 participants were analyzed and assessed for bias using the Cochrane RoB2.0 tool. Video was used in 22 studies (63%), making it the most common modality. Seventy-three percent (16/22) of these studies reported statistically significant improvements in their primary outcomes. Text messaging was used in eight studies, with two (25%) reporting significant improvement in their primary outcomes. WBMs and apps were used in seven studies, 71% (5/7) of which reported statistically significant improvements in primary outcomes. Statistically significant improvements in cognitive outcomes were reported in 64% (18/28) of applicable studies, compared with 17% (4/23) for behavioural outcomes. The results suggest that digital educational interventions can positively impact cognitive outcomes in the emergency department. Video, WBM, and app modalities appear particularly effective. However, digital educational interventions may not yet effectively change behaviour. Establishing guidelines for evaluating the quality of digital educational interventions, and the formal adoption of existing reporting guidelines, could improve study quality and consistency in this emerging field. Registration The study is registered with PROSPERO ID #CRD42023338771.

Addressing technology-mediated stigma in sexual health-related digital platforms: Insights from design team members

Digital health technologies are increasingly used as complementary tools in accessing sexual health-related services. At the same time, there are concerns regarding how some interface features and content of these technologies could inadvertently foment stigma among end users. In this study, we explored how design teams (i.e., those involved in creating digital health technologies) might address stigmatizing components when designing sexual health-related digital technologies. We interviewed 14 design team members (i.e., software engineers, user interface and user experience (UI/UX) designers, content creators, and project managers) who were involved in digital health design projects across two universities in western Canada. The interviews sought to undersand their perspectives of how to create destigmatizing digital technologies and were centered on strategies that they might adopt or the kind of expertise or support they might need to be able to address stigmatizing features or content on sexual health-related digital technologies. The findings revealed two overarching approaches regarding how digital health technologies could be designed to prevent the unintended effects of stigma. These include functional design considerations (i.e., pop-up notifications, infographics, and video-based testimonials, and avoiding the use of cookies or other security-risk features) and non-functional design considerations (i.e., adopting an interprofessional and collaborative approach to design, educating software designers on domain knowledge about stigma, and ensuring consistent user testing of content). These findings reflected functional and non-functional design strategies as applied in software design. These findings are considered crucial in addressing stigma but are not often apparent to designers involved in digital health projects. This suggests the need for software engineers to understand and consider non-functional, emotional, and content-related design strategies that could address stigmatizing attributes via digital health platforms.

Mapping the evidence on interventions that mitigate the health, educational, social and economic impacts of child marriage and address the needs of child brides: a systematic scoping review

More than 650 million women alive today were married as children. Relative to efforts to prevent child marriage, efforts to support child brides have received much less attention. This review set out to map and describe interventions that support child brides. We performed a scoping review using seven electronic databases coupled with a grey literature search in January 2022. Data were extracted using a piloted extraction tool and findings were reported in narrative synthesis. A total of 34 projects were included in our review. Most projects focused on improving sexual and reproductive health (SRH) knowledge and behaviours among child brides, which was often achieved through a combination of SRH education, counselling and information provision, along with linkages to SRH services. Some interventions were health facility-based and aimed at improving responsiveness of health service providers to the needs of child brides. Very few described economic interventions as one component of a broader health intervention, and only three interventions focused on improving girls' educational outcomes. We also note the paucity of media-based interventions, despite their popularity among adolescents. Over time, interventions addressing the needs of child brides have increased, but the preponderance of evidence has focused on SRH interventions, with interventions that couple education with adolescent-friendly health services demonstrating promise. Interventions addressing other areas of health and social wellbeing of this group, such as mental health, sexual health, and economic independence, have been overlooked in comparison. The review highlights the need for additional empirical evidence on what works to support child brides.

Efficacy of Digital Health Interventions Used for Adolescent's Sexual Health: An Umbrella Review

Background and Aims

Adolescents face many barriers and challenges associated with sexual and reproductive health (SRH). These barriers can include limited access to youth-friendly healthcare services, lack of information, and stigma. Digital health interventions has the capability to enhance clinical management. This study was performed to investigate the efficacy of digital health interventions used for adolescent's sexual health.

Methods

This Umbrella Review has reviewed the search engines and databases of PubMed, Web of Science, Scopus, Chochrane Library, Google Scholar in English with the keywords organized into three broad categories: Sexual health and related issues, digital health interventions, and Adolescent, until December 3, 2023. The final analysis was based on a review of 23 full-text articles.

Results

The findings of the study clearly demonstrate the effectiveness of digital health interventions in enhancing sexual health outcomes among adolescents. The review identified several significant fields where digital health interventions have been effective, including promoting safer sexual practices, improving sexual health knowledge, and Minimizing high-risk sexual behaviors among adolescents. The assessment also emphasized the potential of digital health interventions to reach a wide audience, particularly those who may not have access to traditional healthcare services.

Conclusion

The findings of this research suggest that digital health interventions can be an effective way to promote safer sexual practices, improve sexual health knowledge, and reduce risky sexual behavior among adolescents. The quality of the evidence, however, varied across the studies assessed, highlighting the need for further rigorous study to demonstrate the efficacy of these interventions.

Trial Registration

PROSPERO CRD42023488296; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023488296.

Assessing the Effectiveness of an mHealth Intervention to Support Men Who Have Sex With Men Engaging in Chemsex (Budd): Single-Case and Pre-Post Experimental Design Study

BACKGROUND

This study focuses on the Budd app, a mobile health intervention designed for gay, bisexual, and other men who have sex with men who participate in chemsex. Chemsex, the use of psychoactive drugs in a sexual context, presents substantial health risks including increased HIV transmission and mental health issues. Addressing these risks requires innovative interventions tailored to the unique needs of this population.

OBJECTIVE

This study aims to evaluate the effectiveness of the Budd app in promoting drug harm reduction practices among its users, focusing on knowledge, behavioral intention, risk behavior awareness, and self-efficacy.

METHODS

The study used a mixed methods approach, combining a single-case experimental design and a pre-post study. A total of 10 participants from an outpatient clinic were recruited, and each attended the clinic 3 times. During the first visit, participants installed a restricted version of the Budd app, which allowed them to report daily mood and risk behavior after chemsex sessions. Phase A (baseline) lasted at least 2 weeks depending on chemsex participation. In the second visit, participants gained full access to the Budd app, initiating phase B (intervention). Phase B lasted at least 6 weeks, depending on chemsex participation, with identical data input as phase A. Participants completed pre- and postintervention surveys assessing behavioral determinants during the first and third visit.

RESULTS

The study observed an increased knowledge about chemsex substances postintervention, with a mean percentage improvement in knowledge scores of 20.59% (SD 13.3%) among participants. Behavioral intention and self-efficacy showed mixed results, with some participants improving while others experienced a decrease. There was also a variable impact on awareness of risk behavior, with half of the participants reporting a decrease postintervention. Despite these mixed results, the app was generally well-received, with participants engaging with the app's features an average of 50 times during the study.

CONCLUSIONS

The Budd app showed effectiveness in enhancing knowledge about chemsex substances among gay, bisexual, and other men who have sex with men. However, its impact on safe dosing behavior, behavioral intention, self-efficacy, and risk behavior awareness was inconsistent. These findings suggest that while educational interventions can increase knowledge, translating this into behavioral change is more complex and may require more participants, a longer follow-up period, and additional strategies and support mechanisms.

"It's Your Body and Your Life:" Formative Audience Research to Develop a Sexual Health Campaign with Youth of Color

Young people account for over half of new STI cases and youth of color face increased sexual health disparities. In partnership with Fact Forward, researchers conducted qualitative formative audience research to develop a culture-centered health communication campaign to increase access to and use of sexual health services among youth of color in South Carolina. Grounded in a reproductive justice theoretical framework, this study employed innovative strategies, including training youth ambassadors to moderate peer-to-peer focus groups. A total of 134 participants were recruited for the study with 51 individuals participating in 9 focus groups and 83 respondents completing a web-based survey (ages 15-24). Qualitative data analyses used Nvivo 1.5.1. Statistical analyses used R Studio®. Findings revealed barriers including lack of education about risks. Participants identified dimensions of inequity and the importance of intersectional messaging to address intimacy, sexuality, and trust. They emphasized normalizing conversations about sexual health and the need for important others "in your corner" to provide support. Participants suggested an empowering storytelling approach to reduce shame surrounding sexual health services. Social media emerged as an optimal communication channel. UNC Perceived Message Effectiveness (PME) Scale scores ranged from 4.42 to 4.57 (out of 5) indicating that messages were well received by participants. Sex-positive campaign messaging focused on self-love, empowerment, and taking control of sexual health. This study offers practical suggestions to develop effective communication strategies to reach youth of color to increase use of sexual health services, including contraceptive counseling, STI prevention, screening, and treatment.

Change in sexual and reproductive health knowledge among young women using the conversational agent "Nthabi" in Lesotho: a clinical trial

BACKGROUND

Young women worldwide face problems like unwanted pregnancy and sexually transmitted infections. Providing sexual and reproductive health education to young women in low- and middle-income countries is a priority. It is unknown if using digital health interventions to deliver health education is effective in resource-constrained settings.

METHODS

We conducted an interventional trial among young women in the low-middle-income country of Lesotho to test the impact of the conversational agent system ("Nthabi") designed to deliver sexual and reproductive health information on either a smartphone or tablet for up to 6 weeks. We measured participant's knowledge before and after the discussion of family planning, folic acid use, and healthy eating. The main outcome measure was a change in knowledge among participants in these three topic areas. The number of correct pre- and post-test responses was compared using generalized linear models that directly estimated the proportions and percentages of correct responses.

RESULTS

We recruited 172 young women (mean age 22.5 years, 91% unmarried, 69% completed high school, 23% unemployed, 66% students) to use Nthabi on a mobile phone (11.6%) or loaned tablet device (88.4%). The mean number of interactions with Nthabi was 8.6. Family planning was chosen to be discussed by 82 of the 172 participants (52.2%), and of those, 49 (31.2%) completed the content on this topic, and 26 (16.6) completed the post-test. For the 11 questions about family planning, the total percent of correct responses increased from 85.5% (796 total responses) on the pre-test to 89.9% (320 responses) on the post-test (p = 0.0233). Folic acid use was chosen to be discussed by 74 (47.1%) of 172 participants, and of those, 27 (17.7%) completed the content on this topic, and all 27 (17.7%) completed the post-test. For the 5 questions about folic acid use, the total percent of correct responses was 45.3% (181 total responses) on the pre-test and 71.6% (111 responses) on the post-test (p < 0.0001).

CONCLUSIONS

The Nthabi conversational agent system increased knowledge of family planning methods and folic acid use among young women in Lesotho. Digital health interventions like Nthabi have the potential to offer new ways to deliver reproductive health information.

TRIAL REGISTRATION

ClinicalTrials.gov registration April 20, 2020; ID: NCT04354168 .

Decisional needs and interventions for young women considering contraceptive options: an umbrella review

BACKGROUND

Although women face a wide range of contraceptive options, globally, young women are at risk of unintended pregnancies. Our umbrella review aimed to determine the decisional needs of nulligravida women aged 11 to 30 considering contraceptive options and identify effective interventions to support their involvement in making decisions about contraceptive use.

METHODS

We followed Joanna Briggs Institute methods for umbrella reviews, theoretically guided by the Ottawa Decision Support Framework. We searched six electronic databases. Two reviewers independently screened citations, extracted data, and appraised quality using AMSTAR2. We analysed findings descriptively.

RESULTS

Of 124 citations, we identified 11 reviews of variable quality (critically low to moderate quality): Six reported decisional needs and 5 reported on interventions. Decisional needs of young women were: (a) information needs about contraceptive options (e.g., mechanism of actions, eligibility, administration, side effects); (b) unclear values (concerns about hormone use) and features of different options (based on their religious values); and (c) need for support and resources (support from society and need for privacy). Compared to controls, decision support interventions including patient decision aids and patient education material increased knowledge and improved discussion of options with their clinicians.

CONCLUSION

Young women making contraceptive decisions experience unmet decisional needs. Effective interventions such as patient decision aids and general patient education materials may address their decisional needs and enhance their level of participation in making contraception decisions. Implications and contribution to the field: Young women's decisional needs when considering contraceptive use are informational needs, unclear values (including religious influences), need for support and resources when facing this decision. Interventions, such as patient decision aid and patient education material can, address decisional needs by improving young women's knowledge about contraceptive options.

CyberRwanda's Pathway to Impact: Results From a Cluster-Randomized Trial of Adolescent Family Planning Knowledge, Beliefs, Self-Efficacy, and Behavior

PURPOSE

CyberRwanda is a digital health intervention designed to increase knowledge of family planning and reproductive health (FP/RH) and access to youth-friendly services in Rwanda.

METHODS

Sixty schools in eight districts were randomized 1:1:1 to one of two CyberRwanda implementation models-self-service (tablet-only) or facilitated (tablet, activity booklet, peer facilitators)-or to control. Students aged 12-19 years were randomly selected to participate. Baseline and 12-month midline surveys assessed intermediate (secondary) outcomes of FP/RH and HIV knowledge, attitudes/beliefs, self-efficacy, and behavior. Prevalence differences (PDs) were estimated using generalized linear mixed models.

RESULTS

There were 5,767 midline participants (51% female, mean/median age: 16 years, 29.9% sexually active). Those in CyberRwanda schools had higher knowledge of emergency contraception (57.3% vs. 47.5%, PD: 0.09, 95% confidence interval [CI]: 0.05-0.13); greater confidence in providing consent (73.3% vs. 68.1%, PD: 0.05, 95% CI: 0.01-0.08), negotiating partner's contraceptive use (88.3% vs. 85.0%, PD: 0.03, 95% CI: 0.01-0.06), and accessing/using contraceptive services (95.6% vs. 91.8%, PD: 0.03, 95% CI: 0.02-0.05); and more favorable views on FP/RH services (54.5% vs. 48.5%, PD: 0.06, 95% CI: 0.02-0.11) and condoms (76.9% vs. 71.3%, PD: 0.06, 95% CI: 0.03-0.08) compared to control. No significant differences in HIV/fertility knowledge, confidence in accessing HIV testing, or condom use were observed.

DISCUSSION

CyberRwanda increased FP/RH knowledge, supportive attitudes/beliefs, self-efficacy, and behavior at 12 months. The 24-month endline analysis will reveal whether CyberRwanda's benefits on intermediate outcomes result in changes to the primary outcomes, including contraception use and childbearing.

Usability and Acceptability of a Conversational Agent Health Education App (Nthabi) for Young Women in Lesotho: Quantitative Study

BACKGROUND

Young women in Lesotho face myriad sexual and reproductive health problems. There is little time to provide health education to women in low-resource settings with critical shortages of human resources for health.

OBJECTIVE

This study aims to determine the acceptability and usability of a conversational agent system, the Nthabi health promotion app, which was culturally adapted for use in Lesotho.

METHODS

We conducted a descriptive quantitative study, using a 22-item Likert scale survey to assess the perceptions of the usability and acceptability of 172 young women aged 18-28 years in rural districts of Lesotho, who used the system on either smartphones or tablets for up to 6 weeks. Descriptive statistics were used to calculate the averages and frequencies of the variables. χ2 tests were used to determine any associations among variables.

RESULTS

A total of 138 participants were enrolled and completed the survey. The mean age was 22 years, most were unmarried, 56 (40.6%) participants had completed high school, 39 (28.3%) participants were unemployed, and 88 (63.8%) participants were students. Respondents believed the app was helpful, with 134 (97.1%) participants strongly agreeing or agreeing that the app was "effective in helping them make decisions" and "could quickly improve health education and counselling." In addition, 136 (98.5%) participants strongly agreed or agreed that the app was "simple to use," 130 (94.2 %) participants reported that Nthabi could "easily repeat words that were not well understood," and 128 (92.7%) participants reported that the app "could quickly load the information on the screen." Respondents were generally satisfied with the app, with 132 (95.6%) participants strongly agreeing or agreeing that the health education content delivered by the app was "well organised and delivered in a timely way," while 133 (96.4%) participants "enjoyed using the interface." They were satisfied with the cultural adaptation, with 133 (96.4%) participants strongly agreeing or agreeing that the app was "culturally appropriate and that it could be easily shared with a family or community members." They also reported that Nthabi was worthwhile, with 127 (92%) participants reporting that they strongly agreed or agreed that they were "satisfied with the application and intended to continue using it," while 135 (97.8%) participants would "encourage others to use it." Participants aged 18-24 years (vs those aged 25-28 years) agreed that the "Nthabi app was simple to use" (106/106, 100% vs 30/32, 98.8%; P=.01), and agreed that "the educational content was well organised and delivered in a timely way" (104/106, 98.1% vs 28/32, 87.5%; P=.01).

CONCLUSIONS

These results support further study of conversational agent systems as alternatives to traditional face-to-face provision of health education services in Lesotho, where there are critical shortages of human resources for health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04354168; https://www.clinicaltrials.gov/study/NCT04354168.

Digital applications as a means for promotion of healthy behaviours among Albanian children

Digital applications can be effective tools for strengthening school-based health education programs as they can provide valuable health information to children through interactive videos, quizzes and games. We aimed at assessing the change in the prevalence of healthy behaviours among children exposed to digital applications (intervention) employed for promoting healthy behaviours. We conducted a cross-sectional study before the intervention in March 2022 including a representative sample of 1500 Albanian schoolchildren (≈54% girls) aged 12-15 years. In June 2022, after 4-month exposure to digital applications aimed at promoting healthy behaviours (intervention), we carried out a second cross-sectional study in the same sample of schoolchildren. In both survey rounds, an anonymous and structured self-administered questionnaire inquired children about a range of behavioural practices including nutrition, oral health, physical activity and hygiene practices. After the intervention, overall, there was evidence of a significant increase in the prevalence of all healthy behavioural practices measured: ~9% for breakfast consumption and/or environmental protection, 12% for toothbrushing, 14% for handwashing, 15% for leisure time physical exercise and 24% for adequate fruit and vegetable intake (all p < 0.001). Engagement in healthy behaviours only after the intervention was higher among rural children (from 18% for breakfast consumption to 37% for handwashing and/or adequate fruit and vegetable intake) and especially those pertinent to Roma/Egyptian communities (from 18% for breakfast consumption to 46% for adequate fruit and vegetable intake), except for engagement in safe environmental protection which was more prevalent among urban residents (28% vs. 15% among rural children) and ethnic Albanian children (24% vs. 13% among Roma/Egyptian children). Our findings from Albania indicate that digital applications can be useful for strengthening school-based health promotion programs.