Digital self-care for improved access to family planning and reproductive health services among adolescents in Rwanda: preliminary findings from a pilot study of CyberRwanda

Figures & data

Figure 1. CyberRwanda timeline

Table 1. CyberRwanda design methods and intervention using a human rights approach to self-care for sexual and reproductive health and rights¹⁶

Human Rights Standards^Citation16	Design phase methods and findings	Final intervention design components
The right to health, including availability, accessibility, acceptability and quality of information, goods, and services	CyberRwanda was designed in collaboration with more than 1000 youth, providers, teachers, and community members using a participatory, youth-driven design approach23 to identify key challenges for youth and address barriers to quality care.	All content on the platform is age-appropriate and aligned with national and international evidence-based practices on comprehensive sexuality education.
	The final CyberRwanda product was prototyped with adolescents with diverse levels of literacy, digital access, and fluency to maximise accessibility.	The web-comic and FAQ content is designed specifically for those with both low and high literacy levels.
The right to participation	The design research, prototyping, and pilot phases aimed to maximise participation in CyberRwanda for both in- and out-of-school youth and ensure that the STORIES, LEARN, and SHOP functions were accessible and understandable to all youth regardless of access to a mobile device.	Youth are provided with information to make their own FP/RH related decisions. The SHOP offers details on health products, side-effects, and uses. The STORIES component models conversations with health providers and parents to support youth in navigating challenging conversations about their health.
		Pharmacists are trained to provide youth-friendly care and identify provider bias to improve quality of care.
The right to equality and nondiscrimination	Participants in the design process were sampled to ensure diverse representation with regard to socio-economic status, gender, age, educational status, and social vulnerabilities (former sex workers, insecurely housed youth, domestic workers).	To reach youth with and without access to technology, CyberRwanda is offered on tablets installed in schools and youth centres, and on personal devices.
		To reach youth who may not be in school, CyberRwanda is offered in youth centres.
		To ensure all content is non-discriminatory, content was reviewed by local and global gender, health, and other experts, validated by youth, and approved by the Ministry of Education and the Health Communications Technical Working Groups.
The right to information	A key finding from the formative and design research processes was that youth lack access to accessible, accurate, and clear FP/RH information.	Youth set the priority topic areas, suggested the FAQs covered in LEARN and co-designed how the information is delivered. The information provided was tested and validated with youth to help ensure that it is understandable and meets their needs.
The right to informed decision-making	Formative and design research revealed main barriers to care including fear of judgment and method refusal by providers. Providers were reported to act as “gatekeepers” to accessing methods and to hold non-evidence-based beliefs on the side-effects and safety of contraceptive methods for adolescents.	The SHOP is a direct-to-consumer feature of the platform that was designed to put accurate information and healthcare products directly in the hands of youth and reduce barriers associated with gatekeeping and fear of judgement. Youth are guided when medically necessary to an additional directory of medical services to access other services e.g. pregnancy testing or HIV testing.
The right to privacy and confidentiality	Privacy and confidentiality were identified during the design phase as priority areas for youth. In early CyberRwanda prototypes, clinics were originally intended as the sole site for CyberRwanda service linkages. During subsequent research and prototyping, the focus shifted to pharmacies in response to youth preferences for more private, confidential care.	CyberRwanda enables private and confidential ordering of potentially taboo or stigmatised products. From order to pick-up, the service is designed so that only the young person knows the product they ordered and never needs to discuss with a pharmacist.
		All data from the CyberRwanda platform is gathered and stored in compliance with General Data Protection Regulation guidelines. No identifiable data are collected from users and a privacy policy is available in Kinyarwanda and English in non-technical language.

Figure 2. CyberRwanda platform features and implementation models

Table 2. Primary outcomes for CyberRwanda pilot study

Primary outcome	Indicator	Data source
Acceptability	Suitability of CyberRwanda for youth, including whether the platform content was relevant to youth needs and interests	In-depth interviews
	Support for CyberRwanda by school, youth centre, and pharmacy stakeholders
Feasibility	Ability for integrate CyberRwanda in schools and youth centres	In-depth interviews
	Capacity to support CyberRwanda implementation
Engagement	The proportion of students in participating pilot schools who had heard of CyberRwanda platform	Quantitative surveys; in-depth interviews
	The proportion of students in participating pilot schools who had used CyberRwanda (overall, and by-product feature)
	Student interest and demand for CyberRwanda

Table 3. Demographics of students completing quantitative surveys, Rwanda, 2019–2020

	Facilitated (N = 100)	Self-service (N = 58)	Overall (N = 158)
Age
Mean (SD)	15.8 (2.09)	15.9 (1.44)	15.8 (1.87)
Median [Min, Max]	16.0 [12.0, 19.0]	16.0 [12.0, 19.0]	16.0 [12.0, 19.0]
Sex
Female	54 (54.0%)	35 (60.3%)	89 (56.3%)
Male	46 (46.0%)	23 (39.7%)	69 (43.7%)
School level
S2	29 (29.0%)	33 (56.9%)	62 (39.2%)
S3	31 (31.0%)	19 (32.8%)	50 (31.6%)
S4	40 (40.0%)	6 (10.3%)	46 (29.1%)
Sexually active	17 (17.0%)	2 (3.4%)	19 (12.0%)
Using modern method^a,b	10 (10.0%)	1 (1.7%)	11 (7.0%)
Ever been pregnant^a	0 (0.0%)	0 (0.0%)	0 (0.0%)
Ever given birth*	0.0%	0.0%	0.0%
Ever tested for HIV*	49 (49.0%)	21 (36.2%)	70 (44.3%)
Ever used HIV self-test	2 (2.0%)	5 (8.6%)	7 (4.4%)

^a Primary outcomes for the CyberRwanda impact evaluation.

  ^b Assessed among sexually active students only.

Table 4. Knowledge and use of CyberRwanda by students, overall and stratified by implementation model (facilitated or self-service)

Engagement type	Facilitated (N = 100)	Self-service (N = 58)	Overall (N = 158)
Heard of CyberRwanda	96 (96.0%)	58 (100%)	154 (97.5%)
	Facilitated (N = 96)	Self-service (N = 58)	Overall (N = 154)
Used CyberRwanda	45 (46.9%)	53 (91.4%)	98 (63.6%)
	Facilitated (N = 45)	Self-service (N = 53)	Overall (N = 98)
Used to learn about contraceptives	22 (48.9%)	39 (73.6%)	61 (62.2%)
Used to order products	8 (17.8%)	10 (18.9%)	18 (18.4%)
Used to plan for their future	11 (24.4%)	18 (34.0%)	29 (29.6%)

World Health Organization. WHO Consolidated Guideline on Self-Care Interventions for Health. Vol. 23; 2019. https://apps.who.int/iris/bitstream/handle/10665/325480/9789241550550-eng.pdf

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WHO. Global Consensus Statement Meaningful Adolescent & Youth Engagement. Engag Meaningful Youth. Published online 2016:4–7.

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