Background
Digital health interventions are a promising approach for increasing access to health information and services, but low or non-sustained engagement can limit effectiveness. We examined how exposure to and engagement with a digital family planning and reproductive health (FP/RH) intervention (“CyberRwanda”) influenced the intervention’s impact for Rwandan adolescents.
Methods
A 3-arm, cluster randomized, hybrid effectiveness-implementation trial was conducted with 6,078 students in 60 secondary schools from 2021-2023. Schools were randomized 1:1:1 to CyberRwanda self-service (self-guided access to digital platform), CyberRwanda facilitated (self-guided and group access plus in-person activities), or comparison (no access). Dose-response, treatment on the treated, and complier average causal effects (CACE) were estimated to determine the intervention’s impact among participants with varying levels of school exposure (any, <12 vs. ≥12 months) and platform engagement (high vs. low frequency use, high-frequency plus ≥12 months exposure). The primary outcomes were childbearing, contraceptive use, and HIV testing. Secondary outcomes included FP/RH knowledge, attitudes, self-efficacy, and behavior. Generalized linear mixed models and instrumental variable models were used to estimate prevalence differences (PD) comparing all CyberRwanda participants to the comparison.
Results
Overall, 91.5% of CyberRwanda participants were exposed to the intervention at school. Of these, 62.1% had ≥12 months of exposure; 31.7% were high-frequency users. Exposure time and engagement were found to be the primary drivers of impact. No effects were detected among participants exposed for <12 months; however, the ≥12-month exposure subgroup had significant improvements on several secondary outcomes, including condom use among sexually active participants (56.6% CyberRwanda vs. 44.2% comparison, PD: 0.13, 95% confidence interval: 0.06, 0.21). CACE analyses revealed that, if sexually active participants had ≥12 months exposure and were high-frequency users, condom use could increase by 37 percentage points relative to the comparison arm. There were no effects on the primary outcomes for any of the exposure groups.
Conclusions
When provided with access for a year or more, CyberRwanda has the potential to increase condom use and reduce risk of critical FP/RH outcomes including HIV and unintended pregnancy. These results underscore the need for sustained access to and engagement with digital platforms to achieve impact.