Digitizing reproductive health education

A teenage girl named Happy needs to make a decision: She was offered both a job and an acceptance to university, and needs to choose one. She goes to Mutoni, her mentor, who tells Happy to write down her goals on a piece of paper, keep this list, and study it while making her decision. Once she makes her choice, Happy will start to see how that decision aligns with her goals. And if it doesn’t, she can take a step back in time and choose again.

Happy is an avatar in a gamified digital platform called CyberRwanda, geared toward youth in Rwanda to help them think more clearly about their future.

Developed by YLabs, in partnership with the U.S. Agency for International Development (USAID), the Packard Foundation, and Rwanda’s Society of Family Health, CyberRwanda specifically aims to fill specific gaps in family planning and reproductive health education in Rwanda — gaps partially created by the misinformation and stigma that often make youth-friendly services difficult to access for unmarried young people.

Co-designed with Rwandan youth, this Direct-to-Consumer online platform weaves together choose-your-own-adventure storylines, a robust FAQ library, online ordering, and a clinic locator to deliver integrated age-appropriate adolescent health information, employment skills, and linkage to high-quality, youth-friendly services. CyberRwanda also includes a separate digital training game that helps train pharmacists at partnering clinics on the online ordering program and youth access in Rwanda, sources of bias, and voluntary family planning and reproductive health care.

In 2019, YLabs approached Sandra McCoy, an epidemiologist and associate professor at the UC Berkeley School of Public Health, to conduct a rigorous assessment of CyberRwanda as the platform will be introduced into certain schools across Rwanda starting in March 2020. Over an 18-month period, McCoy, along with Dean Emeritus Stefano Bertozzi and Dr. Laura Packel, research director of McCoy’s team, will evaluate CyberRwanda’s effect on teenage pregnancy rates while improving access to both voluntary family planning methods and HIV testing.

“Part of the goal is to get students to think about future goals,” says Packel. “And one path to opening up your future is delaying pregnancy.”

CyberRwanda is a result of human-centered design. Hundreds of students, parents, and schoolteachers in Rwanda worked side-by-side with the platform’s developers to ensure the intervention addresses their health needs and reflects solutions they would want to adapt.

“These storyboards and characters were really formed from the ground up with the help of the people who live in those situations themselves,” says Packel.

By definition, human-centered design is an approach to problem solving that requires empathy. It involves the perspectives of the population the design is meant to serve. “It sounds like common sense, but in public health a lot of what we do is through the lens of a researcher,” says McCoy. “We assume that people make rational decisions about their health, that people have information about health services available to them, and that they’ll avail themselves of those services. But that’s not always how it works.”

Despite the researchers’ assumptions, people might have competing motivations and preferences, for instance, or cultural factors might influence how communities receive public health interventions. For instance, stigma can exist around the topic of youth-friendly reproductive health services, which could influence the health care that youth receive, including from pharmacies that provide access to contraception, menstrual hygiene products, and other reproductive health information and services. Alongside this stigma comes misinformation concerning contraception, HIV, and family planning.

“Challenges abound for youth that are in need of reproductive health information and services,” says McCoy.

When the team at YLabs met with Rwandan youth, they wanted to hear from them how to best meet these challenges. The adolescent perspective rendered two key points: First, youth in Rwanda, like everywhere, are increasingly using smartphones and tablets. These devices can be a Pandora’s box. With easy internet access comes even more misinformation, just a Google search away. And second, adolescents prefer to receive hygiene products and contraception from pharmacies, where they feel like services are kept private.

Here was an opportunity for a device-based digital platform that could deliver accurate and timely family planning information, and could connect youth to a network of youth-friendly pharmacies.

In spring 2020, YLabs and the Society of Family Health will introduce CyberRwanda into schools across Rwanda, where the Berkeley Public Health research team will measure the platform’s impact on voluntary family planning method usage and HIV testing, The team’s hypothesis is that CyberRwanda will improve both, but time and mix-methods quantitative research will tell.

“We want to know what works and why, what doesn’t work, and how it can improve,” says McCoy. “Few organizations want to subject their programs to rigorous evaluation, so we’re excited to be a part of this partnership with YLabs where everyone is committed to generating evidence about how digital health interventions like CyberRwanda work.”