Applying technology to promote sexual and reproductive health and prevent gender based violence for adolescents in low and middle-income countries: digital health strategies synthesis from an umbrella review

Abstract

Aim

Adolescents in low-and-middle-income countries (LMICs) are facing numerous developmental, sexual and reproductive health (SRH) challenges including exposure to multidimensional violence. Gender-based violence (GBV) specifically intimate partner violence (IPV) are both highly prevalent in LMICs and are strongly linked with poor SRH outcomes. However, GBV and IPV interventions have not yet been adequately integrated in SRH due to individual, social, cultural, service, and resource barriers. To promote long-term SRH, a more holistic approach that integrates GBV and IPV, and adolescent development needs is imperative. Digital health has the potential to address multiple service setup, provision, and addressing access barriers through designing and providing integrated SRH care. However, there are no guidelines for an integrated digital SRH and development promotion for adolescents in LMICs.

Methods

An umbrella review was conducted to synthesize evidence in three inter-related areas of digital health intervention literature: (i) SRH, (ii) GBV specifically IPV as a subset, and (iii) adolescent development and health promotion. We first synthesize findings for each area of research, then further analyze the implications and opportunities to inform approaches to develop an integrated intervention that can holistically address multiple SRH needs of adolescents in LMICs. Articles published in English, between 2010 and 2020, and from PubMed were included.

Results

Seventeen review articles met our review inclusion criterion. Our primary finding is that application of digital health strategies for adolescent SRH promotion is highly feasible and acceptable. Although effectiveness evidence is insufficient to make strong recommendations for interventions and best practices suggestions, some user-centered design guidelines have been proposed for web-based health information and health application design for adolescent use. Additionally, several digital health strategies have also been identified that can be used to further develop integrated GBV-IPV-SRH-informed services to improve adolescent health outcomes. We generated several recommendations and strategies to guide future digital based SRH promotion research from our review.

Conclusions

Rigorous research that focuses on intervention effectiveness testing using a combination of digital health strategies and standardized albeit contextualized outcome measures would be important. Methodological improvement such as adoption of longitudinal experimental design will be crucial in generating evidence-based intervention and practice guidelines for adolescents in LMICs.

Background

Sexual and reproductive health needs and service gaps for adolescents in LMICs

Sexual and reproductive health (SRH) is defined as “a state of physical, emotional, mental, and social wellbeing in all matters relating to sexuality, the reproductive system, and its processes” [1]. SRH services generally cover 9 topic areas, including (i) contraception/pregnancy prevention, (ii) HIV/AIDS, (iii) sexually transmitted infections (STIs), (iv) abortion, (v) antenatal care/delivery/postnatal care, (vi) reproductive tract infections, (vii) infertility, (viii) sexuality, and (ix) partner violence (including violence against women) and related practices (e.g., female genital mutilation) [2]. As part of normal development, adolescents face important decisions related to their SRH, sexual relationships, sexual identity, and sexual activities. They also experience rapid physical (puberty, body shape), cognitive (moral concepts, complex abstract thinking; self-identity), and psychosocial development (peer identification, heterosexual peer interest, sexual orientation, formation of intimate relationship). The domains of SRH and overall adolescent development are interrelated. Because puberty, body image, sexual identity, and intimate partnershipsare part of normative adolescent development, constructing healthy relationships, gaining timely knowledge and practice during the adolescent period can shape future healthy SRH [3, 4]. Because of differences in developmental characteristics between adolescents and adults, health promotion strategies should also be differentiated for adolescents [5]. To effectively promote SRH in adolescents, comprehensive care that includes essential adolescent preventive services (i.e., education, adequate material supply/support, welfare planning) and simultaneously use targeted strategies focusing on adolescents’ unique developmental characteristics (in biological, social, and cognitive domains) and living contexts would matter [6, 7].

Gender-based violence (GBV), an important aspect of SRH, is a highly prevalent problem of public health and social significance in adolescents and young adults in LMICs [8,9,10], and it has a debilitating impact on SRH outcomes. However, adolescent GBV prevention tends to be regimented to adult models that lack developmental contextualization. GBV includes intimate partner violence (IPV), non-partner perpetrated sexual violence, child abuse, female genital mutilation/cutting (FGMC), and child marriage. In this paper we draw attention to the broad practices associated with GBV but keep IPV as an example of most rampant form of violence in youth. An estimated 32–38% of women aged 15–49 years in Sub-Saharan Africa (SSA) experience IPV (one of the most common forms of GBV) in the past year (38–50% lifetime prevalence) [8]. In the Asia Pacific, 8–32% of women aged 18–49 years and 10–34% of men reported IPV experience in the past year, with a higher lifetime prevalence of IPV for men [33–80%] than for women [28–67%] [9]. A trans-regional study based on 46 countries also reported an overall higher prevalence of IPV in younger women (15–19 years old) than the older women (20–34 or 35–49) [10]. High prevalence of GBV specifically IPV is associated with a host of negative SRH outcomes, including high risks for HIV/STIs, abortion, risky sexual behaviors, number of sexual partners, low use of contraception/STI prevention, unintended pregnancies, sexual disempowerment (e.g., sexual communication, relationship equity), and poor mental health [11]. Therefore, both GBV and a strong focus within it on IPV prevention should be deemed as an important area of SRH care in LMIC contexts [11].

Challenges in addressing violence within SRH service context in LMICs can be attributed to complex, multilayered risk factors, limited intervention and implementation evidence, and health policy -and system-level barriers. Specifically, GBV and IPV can be related to a spectrum of individual risks (such as early childhood adversities, multiple traumatic experiences related to GBV, personal characteristics), and sexual partner risks (such as partners’ gender stereotypical views, substance abuse history, unemployment, and infidelity) [9]. Additionally, these may be related to inequitable socio-cultural norms (such as norm experience in witnessed GBV and IPV well before puberty and first dating relationship; and difficulty in disclosing IPV and GBV given culture stigma, shame, and associated fear and guilt). Service gaps can also be due to limited intervention and implementation evidence and a lack of health policy guidelines. Existing adolescent SRH interventions in LMICs have mostly focused on topics related to contraception, family planning, abortion, teen pregnancy, sexually transmitted infections (STIs), and maternal depression [12,13,14,15], and do not adequately address the root causes [11]. Policy guidelines related to safe, and appropriate IPV, GBV, and SRH knowledge dissemination are known to be deficient [16, 17]. Solutions toward GBV management are generally not adolescent-sensitive or consider socio-cultural nuances that might impact how GBV is practiced and how it shapes adolescent developmental experience [11, 17, 18], In part due to lack of knowledge about IPV, training, awareness and prevention skills around service implementation in providers [6, 19] this tends to remain under addressed. Most existing GBV interventions in LMICs focus on women and adults [20, 21], are provided within social welfare or legal services, and are not integrated within SRH services [22,23,24]. Therefore, the burden associated with GBV specifically around IPV continues to adversely impact LMIC populations’ SRH outcomes [7, 25].

Moving towards developing an adolescent-centered and integrated SRH service with use of technology

The Lancet Commission on Adolescent Health and Wellbeing has called for new ways of adolescent health promotion that consider multiple adolescent health and developmental needs and living experience [4]. To effectively promote adolescents’ SRH in LMICs, it is critical to consider a comprehensive integrated approach of service development that addresses developmental, GBV targeting IPV, and service needs that address sexual health promotion [6, 19]. To help the field move towards this integrated approach in the LMIC context, our contribution here is to synthesize evidence in three interrelated areas (SRH, GBV/IPV, adolescent development), and generate lessons to inform future high-impact intervention program development. Given that technology has the potential to offer new cost-effective and longer-term sustainable solutions to address these gaps, our review, and integrated SRH service strategies focus on technology approaches of interventions. In technology and health research, the terms digital health and eHealth are often used interchangeably. eHealth, a broader term used in 2010s defined as the use of mobile health (mHealth), information and communication technology (ICT), computer science, and data to support informed decision-making by individuals, the health workforce, and the health system, to strengthen resilience to disease and improve health and wellness for all [26]. Digital health is a term used much broadly after 2018–2019 when WHO introducing new guidelines. The new term digital health considers art and science aspects of technology (e.g., visual, personalize, communication forms of presentation) [27, 28]. The applications of technology in health holds promise. Digital health can be used for screening, health education, addressing social-cultural and privacy challenges, offering tailored services to individuals, and providing self-help support. It can improve service efficiency, improve coordination, linkages, and be offered easily by non-professionals. Based on these recommendations, it strongly presents itself as a low-cost sustainable model [29, 30] to bridge this gap. A review study based on 66 articles covering Sub-Saharan Africa (SSA) found that eHealth has been applied to address a range of health conditions. These include infectious diseases (malaria, HIV/AIDS), oral health, infant health, maternal health (antenatal/postnatal care, postpartum hemorrhage), non-communicable diseases (cervical cancer, blood pressure), and some areas of mental health (such as depression care) [31]. Most digital health strategies were designed for disease control and prevention, population health monitoring, information provision for treatment/prevention, data acquisition, and patient records management, diagnosis, training/recruiting/retaining health professionals, or decision-making/referrals [31].

In applications of digital health for young people, WHO has proposed a youth-centered digital health intervention framework for planning, development, and implementing solutions for young people [5]. A body of research has also documented the effectiveness of using digital health to facilitate youth self-health management approaches (e.g., chronic illness, mental health) [32,33,34,35] and improved behavioral support to promote youths’ mental health [36,37,38,39,40,41]. Although there is a high percentage of digital device ownership, an emerging trend in LMICs to seek health information from the internet (42–51%) [42,43,44], and the potential of using digital Health to address multiple adolescent health barriers [45], digital health has not been systematically studied in adolescent IPV and GBV intervention for adolescents in LMICs [46, 47].

New implementation science methodologies, like intervention integration, can be applied to systematically adapt and combine existing evidence-based interventions (EBIs) to align them with population needs (interrelated SRH issues), new populations (e.g., adolescents), or implementation contexts (e.g., targeting high GBV contexts), and help the field to develop, select, or tailor implementation strategies to increase adoption, implementation, and sustainability [47, 48]. The combination use of digital health and implementation strategies/methodologies offers new opportunities to create novel approaches of integrated interventions to disrupt the traditional model of SRH access and care to allow for user-friendly solutions. Therefore, in our digital health review, we focus on synthesizing relevant digital health strategies as well as implementation strategies.

Umbrella review aims

As a first step to inform the development of integrated digital health SRH intervention and services, it is critical to first understand current technology applications and digital health strategies applied in inter-related areas of adolescent health to better identify opportunities, leverage existing technology solutions to put in place adolescent engaged integrated SRH care. Numerous digital health review studies have been conducted, but these in our assessment lack a holistic approach for a well-rounded adolescent SRH promotion. This paper is an umbrella review [49] purporting to summarize three inter-related areas of digital health literature to inform the development of adolescent centered integrated SRH services. This review is not intended to replicate the existing review studies. Instead, we aim to provide an overview and summary for each area of literature first; but most importantly, to identify opportunities and strategies for integrations.

Thus, we focus our review to find answers for two broader areas of questions:

• What are the digital health intervention designs, effective digital health implementation strategies, and impact evidence for (i) promoting adolescent SRH, (ii) preventing IPV and GBV, and (iii) promoting adolescent development? As described above, multilevel risks/factors might contribute to poor health in adolescents (described above). We focus on synthesizing literature in digital intervention contents that have been applied in addressing SRH and GBV/IPV needs.

• What are the potential implementation strategies that can be leveraged from the existing three areas of digital health EBI research for furthering adolescent centered, integrated SRH services?

Methods

Literature review approach

An umbrella review is developed, which provides a concise and focused synthesis addressing our research questions mentioned above [49]. As described above, a body of digital health research has been published in SRH, GBV, and adolescent development, this paper focuses on reviewing existing review articles [49] and synthesized high-level key findings from the literature. We included literature from both high-income countries and LMICs because of limited adolescent-focused digital health research from LMICs, and the potential to transport lessons learned to LMICs. To answer the first research question (identifying effective digital health intervention designs and implementation strategies), the PICOS evidence-report framework (suggest reporting Population targeted, digital health Intervention characteristics/design strategies, Comparison, Outcome, and Study type of the targeted studies) was applied to summarize the literature [50, 51]. Considering digital health research is an emerging field and we might not find many systematic review articles, we considered both systematic and less formal review articles. Systematic review, meta-analysis, scoping review, qualitative review, and mixed-methods types of review articles are included. In addition, review articles published in English, between 2010 and 2020, from PubMed (one of the largest databases that cover most health intervention and implementation research), and those that targeted adolescents were included. We limited the articles after 2010 because digital health research prior to 2010 was mainly mobile/cell-phone based and relied on basic text/messaging system [52], which is less relevant to the applications that used today. Our singular focus here is to conduct a comprehensive systematic review for three included areas of research. Table 1 describes the article search terms and strategies applied in identifying articles in each research area. To answer the second question (strategies for integrating GBV-SRH-developmental service for adolescents), we based on a team consensus approach to further identify research and practice strategies from our three areas of review findings that can be integrated to better develop integrated SRH care. We summarize a set of practice recommendations for moving towards adolescent-centered, integrated SRH services.

Table 1 Article search terms and strategies in three areas of eHealth

Results

A total of 17 review articles fit our inclusion criteria for this review (see Table 1). These included 7 review articles from the SRH digital health category, 4 review articles from the GBV including IPV digital health category, and 6 review articles from the adolescent development and behavioral health category. Tables 2, 3, and 4 summarize the evidence for each area of literature using the PICOS framework [50, 51]. Based on the results from each table, we further synthesized and organized digital health findings in six areas: 1) targeted population/users characteristic; 2) topics covered and characteristic of the digital health intervention; 3) digital health strategies and implementation strategies applied; 4) the feasibility of the tested digital health interventions; 5) efficacy/effectiveness evidence and recommendations; 6) gaps in the digital health interventions. We summarize these six areas of findings for each review area.

Table 2 eHealth for adolescent SRH [23, 53,54,55,56,57,58]

Table 3 eHealth for GBV (All Age Groups) [59,60,61,62]

Table 4 eHealth consider adolescent developmental fit and needs [63,64,65,66,67,68]

Findings around digital health for adolescent SRH promotion

Table 2 summarizes SRH digital health intervention studies for adolescent and young adults’ (AYAs’) SRH. Across 7 review studies included in our review, 154 articles and 22 apps were included in the review articles. Overall, we found that most digital SRH interventions focused on both adolescents and young adults (not adolescent-specific), and use diverse digital strategies (text message, social media, interactive strategies) for SRH screening, knowledge promotion, and behavioral intervention. Although several high-quality apps are available, the evidence for promoting SRH is mixed. More theory-guided digital interventions (cognitive, behavior, or ecological framework) and systematically testing digital strategies are needed to improve the impacts. Here we summarize the key findings.

Targeted populations

The populations included in this area of research were all targeted on adolescents and young adults (see Table 2 for age ranges defined in the reviews), and included quite diverse populations (e.g., African American, Latino, LMIC populations, both gender), with one review study focused on adolescents exclusively from eight LMICs [56]. Although diverse populations are considered, most studies did not examine digital health use and impact on SRH separately for younger and older AYAs.

Topics of intervention

United Nations Family Planning Association (UNFPA) suggests covering 9 topic areas in SRH services (described above) [2]. From our review, we found the digital approach of SRH interventions in AYAs were mainly focused on contraception, pregnancy prevention, abstinence promotion [23, 54, 56,57,58], sexual health promotion (on topics related to STIs, HIV/AIDS, safe sex, risky sex behaviors) [23, 53, 55,56,57,58], substance use [53], family planning counseling, abortion care [56], and GBV [56]. The existing AYA e-SRH interventions cover 5 of the 9 SRH areas suggested by the UNFPA, but predominately focus on pregnancy prevention, uptake of contraception, STIs and HIV/AIDS prevention, and treatment referral and follow-up. Only a small aspect of GBV/IPV was included as part of SRH services.

Digital health strategies & functions included

Three themes emerged. For the primary prevention focused SRH interventions, greater emphasis is on using technology to promote knowledge, healthy SRH behaviors (e.g. behaviors for preventing pregnancy), and STI screening and follow-up (through public health campaigns or individual outreach). Some interventions also provide counseling or referral support to link users to essential SRH services when needed (e.g., medically assisted abortion, family planning, STI, HIV care).

There is a wide range of digital health strategies applied in SRH promotion and knowledge dissemination, but the use of technology strategies seems to shift overtime. For example, mobile phone and text messaging were the most frequent options for the study conducted before 2015 [53, 56, 57]. Recent studies have integrated more social media-based strategies (e.g., internet-based social media Facebook, WhatsApp, Twitter, Snapchat, Instagram, blogs, virtual reality, online gaming) [23, 55], and promoted more interactive technology (e.g., accepting input from the users, interactive video games) or technology with tailored functions. Some studies suggested that these new social media strategies can be effective and efficacious in rapidly promoting attitude and norm change around SRH (e.g., promoting safe sex norm, attitude, and condom use attitude) [58]. More research is needed to better understand whether different technology strategies are associated with different levels of engagement and harm/safety issues, which impact AYAs’ SRH outcomes [56].

There are several high-quality mobile apps (my choice by PPT, Safe Sex Tips, Get S.M.A.R.T) developed for adolescent pregnancy prevention. These apps were based on recommended best practice guidelines for pregnancy prevention (see Notes under Table 2 for the best practice guideline) and credible/reputable public health information sources (e.g., US Center for Disease Control/CDC) [54]. The availability of these apps is encouraging, but more evidence for underline mechanisms is needed to understand how apps designed based on best practice guidelines impact short and long-term SRH outcomes [54].

Feasibility, efficacy, effectiveness evidence and gaps

The impact evidence on technology-based SRH promotion is encouraging but mixed. Some general patterns can be drawn from the literature. In sexual health promotion, online social media (Facebook) and other technology-based strategies (computer, texting, web-based, internet-based) have been reported with small but significant positive impacts (d = 0.21-0.26), especially in changing knowledge, negative attitudes, and promoting healthy sexual behaviors (condom use, abstinence, STI screening/follow-up) [23, 55, 58, 70]. These findings tend to be similar by age, gender, country, and intervention dose, and tend to be short-term (not maintained over 6 months) [55, 58]. In SRH promotion, studies using texting and mobile phone strategies [53, 54, 57] have found that texting alone tends not to be sufficient to improve knowledge and practice outcomes of SRH. The combination of text messaging with other strategies (e.g., adding behavioral change strategies/curriculum, financial incentives, educational story-telling, video messaging, psychosocial support/counseling, Q&A bidirectional texting, including use of screening) are more likely to yield higher rates of screening, follow-up, and positive SRH outcomes (knowledge, awareness, unprotected sex, condom use, STI testing) [56, 57]. Future research is needed to test cognitive (knowledge/attitude/belief) and behavioral change theories to study intervention effectiveness mechanisms on sexual health and reproductive health knowledge and practice uptake and maintenance for adolescents and young adults separately given different developmental ability and characteristics [56].

Findings around digital health for GBV prevention

Table 3 summarizes digital health for IPV and GBV for all age groups. Across 4 review studies that we reviewed, 70 digital health articles and 197 applications (apps) in the Apple iTunes and Android Google Play stores were reviewed. Overall, we found that most digital GBV including IPV interventions have focused on female and high-income country populations. Most digital GBV/IPV interventions were focused on secondary or tertiary interventions (not primary prevention) and included diverse digital health strategies (apps-, web-, and/or mobile-based communication strategies). Although feasibility and acceptability of using digital health for GBV/IPV screening and interventions are generally high, there is insufficient effectiveness evidence to support that use of digital health (targeting GBV/IPV risks) would lead to better SRH outcomes. More integrated intervention research (target on multiple risks) and comparative effectiveness research are needed to document how the combination of intervention strategies improves GBV/IPV and SRH outcomes. Below we summarize results in 6 areas.

Targeted populations

The population that most IPV and GBV digital health interventions targeted were women and IPV survivors from high-income countries. Very few studies targeted men or perpetrators [59, 60, 62] or populations in LMICs. No digital health study targeted adolescents specifically or addressed GBV issues. This explains why, adolescent-specific digital health guidelines and strategies to prevent and management of IPV and GBV are not in place.

Topics of intervention

Specific to IPV the digital health interventions that have been developed are for IPV screening and disclosure, prevention and education, mental health interventions, empowerment, and social support purposes. However, most technology-based IPV interventions were secondary or tertiary interventions [59, 60], and only a few were focused on primary prevention. Lack of IPV digital health research in adolescents may explain why IPV and GBV services have not been included [62].

Digital health strategies/functions included

Digital health strategies that have been applied in IPV interventions include: using apps and web-platform for education, using a web or mobile-based communication (including video conferment/telehealth, email), and interaction functions to engage and address participants’ needs. Most IPV interventions apply multiple digital strategies [59, 60, 62]. Open-source apps tend to be designed for sex aid/sexual exploration and entertainment purposes, and are less likely to be used for IPV education [61].

Feasibility

Across studies, feasibility, and acceptability of using digital health for IPV screening and interventions are generally high, but questions addressing safety, equity, and the unintended consequences of the use of digital health in IPV programming are virtually non-existent [60].

Efficacy and effectiveness evidence and gaps

Although some impact evidence suggests that e-IPV interventions could improve understanding of how and why violence occurs, provide knowledge on disclosure, safety, and management skills [60], there is insufficient efficacy or effectiveness evidence to support that IPV digital health would lead to better SRH outcomes [62, 71]. There is also a lack of comparative effectiveness research between digital health and the more conventional IPV and GBV intervention approaches. Outcome comparisons across studies are difficult given standardized measures of SRH, IPV, and GBV outcomes were not used across studies and quite different IPV and GBV intervention contents were included. More research using well-defined and standardized measures is needed.

IPV prevention (especially commonly used educational programs) and screening alone are not sufficient to prevent or intervene for IPV. Inclusion of additional intervention strategies such as improved access to digital health support services (e.g., telehealth, patient-provider e-communication, online support groups, technology-based cognitive-behavioral-therapy/CBT) are more likely to show promising outcomes in reducing IPV risks while promoting SRH. [59]. This suggests that most current SRH programs that include educational material only for the positive and respectful approach to sexuality and sexual relationship might not be sufficient to meaningfully address adolescents’ IPV and GBV needs.

Findings around digital health for adolescent development promotion

Table 4 summarizes digital health applications in promoting adolescent and young people's health and development. Six review studies were included for this review (representing 189 digital health articles). In this category of literature, two review papers focused exclusively on children and adolescents below age 18 (6–18 years old) and considered their developmental characteristics in digital health design and feedback query processes [63, 67]. Remaining four review articles included both adolescents and young adults. Overall, we found adolescents differed from adults in digital health design preference (interactive/ participatory function). Digital health interventions (web-based and app-based interventions) have been applied for psychoeducation and skill development purposes. User-centered design studies have informed the development of several digital-health design guidelines for teens and adolescents. Although evidence has shown feasible of digital health for adolescent health promotion, effectiveness evidence for digital health remains to be limited. Below we summarize results in 6 areas from this area of literature.

Characteristics of the Targeted populations

Adolescent users have unique features and preferences in digital health use. Designing digital health solutions requires careful consideration of their life context, lifestyle, their social processes, low tolerance of delayed gratification, and attraction to novelty [63, 65,66,67,68]. Adolescents also prefer networking opportunities and gaining connections with health providers [66].

Topics of intervention and digital health strategies

mhealth apps and web-based interventions are commonly applied to promote adolescent health literacy and health behaviors. A body of user-testing/feedback studies with adolescents has informed the development of several useful frameworks/guidelines for guiding the design of the mHealth apps for adolescent use [63, 68]. For example, Jeminiwa and colleagues proposed a five-dimensional framework for guiding the design and evaluating the quality of mHealth apps for teens and adolescents. The 5 dimensions include considering the technical quality (such as app ease of use), engagement (such as interactivity), support system (such as decision support, behavioral or learning support feature), autonomy (such as app accessibility in terms of control and cost), and safety, privacy, and trust (such as app credibility, safety) [63]. Reen and colleagues [68] proposed another five-dimensional framework to guide health information website design for adolescents. Reen et al. suggested that a considered website design in the following 5 areas, as well as user suggested strategies in each area, is important (listed below): i) appearance (website with a simple layout and with color), ii) negative burden (easy navigation, simple log-in), iii) content delivery methods (adolescents prefer short videos, images, audio clips, positive stories/testimonial from other peers, animation; content delivered to be easy to comprehend and through peers), iv) message source (website with clear logo and appropriate website name, gender balance), v) interactive/participation functions (prefer using games/quizzes, ability to control/personalize, to interact with professionals or peers, and incentive point-system, social network capability) [68].

Depending on the goal of digital health intervention (for skill development or knowledge promotion), different digital health design and implementation strategies may be applied. For skill development, digital health strategies such as using game/computer-assisted, apps, virtual reality, text messages can be very relevant. For psychoeducation purposes, games or computer-assisted solutions (using photos, stories, quizzes, multimedia audio/video) can be optimal options [65].

Feasibility

It is feasible to apply digital health for adolescent health promotion. Specifically, cognitive-behavior therapy (CBT) is an intervention approach that helps people cope with stress or emotion-behavior challenges. Technology-assisted formats of CBT (iCBT) have been adapted for children and adolescents and have shown to be a feasible approach to help young people manage their emotional stress [67].

Efficacy, effectiveness evidence and gaps

E-mentoring has been recommended as an effective way to support adolescents who face multiple challenges. E-mentoring can be flexible and use multiple existing technologies to support (video call, email), and can be equally effective as face-to-face mentoring. E-mentoring can promote self-confidence, skill development, and coping with daily life [64]. Evidence from e-mentoring can be relevant to SRH promotion.

Most digital health review studies included in this developmental category have been focused on identifying effective, safe, trusted, engaged, and developmentally appropriate digital health models of delivery and strategies that fit different developmental stages preferring more qualitative and mixed-methods types of study designs. They have not focused on effectiveness evaluation (given multiple health topics were considered).

Discussion

Our umbrella review of three inter-related areas of research has provided deeper insights to understand current challenges in advancing short and long-term SRH and socioemotional development in young people living in LMICs. In each area of review, we focused on synthesizing findings for 6 areas of questions: (i) which populations and users have been targeted in the digital intervention research; (ii) what areas of SRH topics have been covered in the digital health interventions; (iii) what technology platforms/application and digital implementation strategies have been used in these studies; (iv) whether/what digital health strategies are acceptable and feasible; (v) what impact evidence and related recommendations have been documented from the digital intervention studies; and (vi) which under-studieddigital intervention research strategies need to be prioritized in future research. Our review contributes to new knowledge in applying technology and ICT strategies for SRH and GBV/IPV intervention and implementation strategy.

In the digital SRH research, we found most interventions have focused on applying intervention delivery models and strategies that have been tested in adults and applied similar intervention models without differentiation to adolescents. Adolescent developmental characteristics and needs (e.g., emotion, cognitive comprehension, material, identity, both peer and family support needs) have rarely been discussed in digital SRH design or for example in reproductive care for pregnant adolescents. Similarly, for the digital GBV and IPV research, we found most solutions have focused on secondary and tertiary interventions in women, victims, and adults. The technology approach of GBV interventions have not been offered from preventive and skill-building perspectives or considered targeted adolescents such as younger-aged boys and girls, and altogether these have not focused on beliefs/attitudes and behavioral change as outcomes of interest. In the field of adolescent development research, we found great progress has been made in identifying developmentally appropriate and engaged digital health strategies and platforms for different health promotion goals (e.g., education/knowledge learning, communication, mentoring, support, information dissemination/sharing, health behavioral change). These user-centered design thinking and guidelines are useful for future digital SRH, and GBV/IPV intervention design and testing. Overall, across our highlighted areas of literature, consistent findings on high feasibility and acceptability using digital health strategies for adolescent SRH, IPV, GBV, and development promotion have been documented. However, effectiveness research evidence for digital health intervention is insufficient and mixed, especially for tracking broad health and long-term SRH outcomes. More adolescent population-specific e-intervention evidence is urgently needed.

Recommendation for integrating GBV-SRH-developmental service for adolescents in LMICs

To identify strategies and draw recommendations for integrated GBV/IPV prevention within SRH services that fit the development of adolescents, we synthesized our review observations and our group’s adolescent health research experience to further identify opportunities and strategies which hold promise. As authors reviewed the findings and have generated key recommendations. Below, we provide five sets of recommendations that hold promise to developing integrated services.

Starting from youth service provider education and community awareness campaigns

The current GBV/IPV, and SRH service integration gaps can be attributed to a lack of knowledge and inadequate skills in addressing inter-related adolescent health issues in service providers, school staff, and parents/caregivers of adolescents. Several digital health strategies identified from this review are promising and can be applied for education purposes (such as web-based training modules, virtual video, simulated videos), decision-support purposes (e.g., tablet-based screening, decision support for interventions), and information dissemination/awareness campaign purposes (e.g. social media). Some IPV studies have focused on training providers (e.g., midwives) to provide tablet-based IPV screening and detection, and early intervention to promote safe behaviors in peripartum women and adolescents [72]; or to use simulated nursing video consultations to train nurses in GBV clinical management or referrals (which also improved nurses’ GBV awareness and victim management knowledge and skills) [73]. Applying similar digital health strategies to improve adult caregivers, primary care staff, school staff, and community youth service providers’ knowledge and competency in supporting adolescents’ GBV, IPV, SRH, and development can be prioritized.

Providing integrated SRH service by building on the existing recommended high-quality e-SRH tools and strengthening the existing e-SRH service platforms

Multiple service settings (i.e., medical/clinical, community service, social service, juvenile justice, youth center, schools, legal service, homes), and existing e-SRH platforms (web-based, internet-based, mobile-based, new media) have been set up for providing SRH, GBV, and developmental preventive services. There are also high-quality SRH apps/tools that are based on the best practice guidelines (e.g., my choice by PPT, Safe Sex Tips, Get S.M.A.R.T) developed. Therefore, strengthening the capacity of the existing e-SRH delivery system and platform to further provide age-appropriate and evidence-informed GBV (including IPV) services can be a potentially cost-effective strategy to offer integrated care. As discussed above, GBV are complex social problems that can be attributed to multi-level factors. When strengthening the existing e-SRH system, additional digital strategies for social norm change (e.g., social media), e-psychosocial support and professional support strategies (e.g., Q&A support strategies) and service linkages should be integrated as well in order to set up a pathway of care from preventive to referral and treatment services.

Applying multiple technology strategies based on the feasibility and user-feedback findings

Across the reviewed literature, there is a consistent finding reporting high feasibility and acceptability towards integrating digital health strategies for adolescent SRH, GBV/IPV and development promotion. In AYAs’ sexual health promotion, it has been found that online social media (Facebook) and other technology-based strategies (computer, texting, web-based, internet-based) resulted in meaningful short-term impacts in changing knowledge, negative attitudes, and by promoting healthy sexual behaviors. In the field of SRH promotion, it has been found that a combination of using texts and mobile phone strategies with other digital health strategies (e.g., adding behavioral change strategies/curriculum, financial incentives, Q&A bidirectional texting) has the potential to yield higher rates of screening, follow-up, and positive SRH outcomes. In the adolescent development field, several digital health strategies have been identified to be useful for skill and healthy behavior development (e.g., using a game, apps, virtual reality, text messages, technology-assisted formats of iCBT), for psychoeducational purposes(e.g., games or computer assist using photos, stories, quizzes, multimedia audio/video, E-mentoring via video call, email using peer-to-peer or adult-to-adolescent), and promoting adolescent self-confidence, skill development, and coping with daily life stressors. These need to be further optimized. Building on this evidence and further studying feasible strategies with a diverse group of adolescents in LMICs using standardized outcome measures will be an important next step to generate effective digital health evidence for adolescent health and development.

Engaging adolescents from diverse backgrounds for testing integrated e-SRH service design and dissemination will lead to greater insights

Learning from findings around adolescent development, we found adolescents are different from adults with regards to their digital health design preferences. They prefer certain digital health delivery methods, communication strategies, engagement approaches, and ways for gaining support from peers and health care professionals. Additionally, we also identified that digital health designs need to fit with the lifestyle of adolescents in order to have greater traction and uptake. Therefore, integrating e-SRH, and GBV services need to consider the needs and lifestyle of vulnerable sub-population, including pregnant and non-pregnant adolescents, boys and girls, and school and out-of-school adolescents. Engaging adolescents from these diverse groups in design, dissemination, and service provision processes can lead to enhanced user-centered, integrated e-SRH care that can speak to the diversity of stakeholders that need to be considered for the advancement of the field [70, 74].

Providing the integrated e-SRH preventive service in diverse primary care and community settings using multiple digital health strategies to reach non-clinical populations

SRH and GBV are considered as common health and developmental health topics that need to be addressed through universalizing preventive care. However, the existing GBV interventions tend to focus on IPV, victims and women/girls, but do not target men/boys or lower-risk adolescents who need empowerment and skills in time. To have greater population reach in SRH promotion and GBV prevention, schools and community organizations can become ideal settings to provide integrated preventive e-GBV- SRH solutions and skills, especially for adolescents. Future research can engage adolescents and service providers from these settings to further test appropriate digital health strategies. This may include using mobile- or internet-delivered self-guided digital health models or cognitive behavior therapy (iCBT) for GBV that incorporated emotion-regulation/social emotion skill development and conflict-resolution techniques in combination with other e-support strategies [75].

In summary, our study is the first to integrate multiple areas of digital health intervention literature. Our paper is an attempt to identify strategies to improve quality and age-appropriate SRH services for adolescents in LMICs. Although this work has contributed to new knowledge, one key limitation should be kept in mind. Specifically, we did not conduct an extensive systematic review. Therefore, some digital health studies for adolescents may be missing (e.g., digital health intervention research for adolescents).

This review was not without its limitations. The use of the one databased (PubMed) might not eliminate databased bias issue. Our choice of search terms (i.e., eHealth and mHealth) might exclude some digital health studies. Finally, we have used an umbrella review strategy, while that adds strength to our overall findings primary studies have not been looked at for rapid evidence synthesis. The review was carried out in 2021 and the findings of this work need to keep in mind that the field has moved since then. However our broad strategies and recommendations we think still apply. Our search terms may not have captured all aspects of SRH especially the reproductive health and rights in particular. Given that the focus was on youth we think we may have still captured broad domains.

Conclusion

We reviewed digital health intervention literature in SRH & GBV specifically focusing on IPV, and adolescent development promotion and prevention fields to identify models of delivery, digital health intervention designs, and promising digital health strategies. Our umbrella review underscores that applying digital health strategies (from traditional text messaging to more recent diverse media approaches) for adolescent health and development promotion is a highly recommended, feasible and acceptable solution. Our paper has identified many useful digital intervention and technology strategies to improve quality and age appropriate SRH services for use with adolescents in LMICs. Although effectiveness research is insufficient to make strong practice recommendations, user-center design guidelines are well-developed for web- and app-based digital health design for use by adolescents. We were also able to identify strategies, digital health tools, and digital health platforms that can be leveraged to further develop an integrated GBV-SRH-development service. We conclude by providing an Adolescent-Centered Integrated SRH Intervention conceptual framework and offering five sets of key recommendations for guiding future integrated SRH, GBV/IPV prevention and developmentally appropriate services in LMICs. Continued evidence generation with a focus on multiple digital health strategies along with standardized outcome measurement in adolescents and sub-adolescent populations are highly recommended. Alongside we urge use of longitudinal experimental designs that will be crucial in the generation of evidence-based interventions and practice guidelines for emerging needs of adolescents in resource constraint regions.