Sexual and reproductive health mobile apps: results from a cross-sectional values and preferences survey to inform World Health Organization normative guidance on self-care interventions

ABSTRACT Mobile application (app) platforms have the potential to advance sexual and reproductive health (SRH). Yet there is a dearth of knowledge regarding global perspectives from healthcare providers on how SRH mobile apps are being leveraged in their healthcare practice. In 2019 the World Health Organization (WHO) developed a consolidated guideline on self-care interventions for SRH. To inform this guideline, we conducted a global values and preferences survey. This study aimed to (a) understand the awareness, access, and uptake of SRH mobile apps; (b) examine how many healthcare provider (HCP) participants provided linkages, referrals and information to clients regarding SRH mobile apps; and (c) among HCP, assess how many felt confident and informed regarding SRH mobile apps. We hosted a cross-sectional web-based survey on the WHO Department of Reproductive Health and Research website and shared the survey with SRHR listservs. There were 825 survey participants, 360 whom identified as healthcare providers (HCP). Approximately one-third of HCP participants had provided a referral/information to their clients about sexual or reproductive health apps. While 40.8% of HCP felt confident and informed about sexual health apps, half (47.4%) reported needing more information, and 15.6% expressed interest in receiving training to use in practice. While 42.6% of HCPs felt confident and informed about reproductive health apps, 45.7% needed more information, and 15.1% were interested in further training. There was also an open-ended question for HCP to share their thoughts about self-care SRH interventions. Specifically regarding SRH apps, HCP responses revealed the importance of considering: (a) security and confidentiality; (b) potential benefits of SRH apps for underserved groups (i.e. youth, rural communities); (c) community engagement; (d) health benefits; and (e) and online training for HCP on SRH mobile apps. Findings signal interest and opportunities for training and engaging HCP in using mobile apps to advance SRH.


Background
Understanding global perspectives from healthcare providers on access and uptake of digital technologies and mobile platforms provides insight into opportunities to advance sexual and reproductive health (SRH). Findings are presented from a global values and preferences survey (GVPS) [1] regarding SRH mobile applications (apps) that informed the 2019 World Health Organization (WHO) Consolidated guideline on self-care interventions for health: sexual and reproductive health and rights [2].
The WHO Guideline Recommendations on Digital Interventions for Health System Strengthening identified digital technologies as a way to increase universal health coverage and defines digital health interventions as 'a discrete functionality of digital technology that is applied to achieve health objectives and is implemented within digital health applications and ICT systems' [3]. Digital technologies were further delineated in the WHO Classification of Digital Health Interventions into client, healthcare provider, health system manager, and data services focused [4].
Digital technologies have the potential to facilitate innovative, efficient ways of meeting growing global health needs. A 2019 report [5] indicated that there are over 5 billion mobile phone users, 4 billion internet users, and 3 billion active social media users, with most accessing the internet through mobile devices. The anonymity, convenience, and accessibility afforded by short messaging services (SMS), web access, and video streaming enhance the potential for SRH interventions to reach persons disconnected from mainstream SRH services.
Governments are leveraging digital technologies to strengthen health systems to ensure record sharing and client monitoring [6]. Health innovators have developed myriad apps and other channels (e.g. SMS) to increase information access. A scoping review [6] identified that improved access, provision, and engagement with sexual health information and care were the primary benefits of digital sexual health communication interventions. A systematic review of mobile phone interventions for adolescent SRH reported that SMS health promotion campaigns contributed to improved SRH outcomes [7]. Applying digital technologies to SRH self care may increase SRH information and resources access [8]. For instance, for self-care interventions such as HIV self-testing [9], digital technologies could facilitate further support via mobile phones, instructional videos, or SMS. Thus, the use of digital technologies for SRH self care could improve correct use of interventions, and empower individuals to better manage their health [8]. Mobile apps for SRH may be used by lay persons for particular functions (e.g. acquiring information) and by healthcare providers (HCP) in numerous ways (e.g. consulting with remote clients) [4]. Yet there is limited global evidence regarding HCP's knowledge and comfort with digital technologies such as mobile apps for promoting and/or using SRH self-care interventions (Table 1), or their training needs and preferences. Our research questions were: (a) across global regions, what is the awareness, access, and uptake of SRH mobile apps?; (b) among HCP, how many have provided linkages, referrals, and information to clients regarding SRH mobile apps?; and (c) among HCP, how many feel confident and informed regarding SRH mobile apps, and how many would like further information and training?

Methods
The GVPS was a self-administered online cross-sectional survey, approximately 20 minutes in duration, conducted between July 2018 and November 2018 in English, Spanish and French. Inclusion criteria were being aged 18 and over, able to read one of the survey languages, and able to provide informed consent. Research Ethics Board approval was attained from the University of Toronto. Participant recruitment was conducted by hosting the survey on the WHO Department of Reproductive Health and Research website [10] and sharing the survey link with diverse (>35) SRHR listservs. To reduce response bias, surveys were anonymous and questions were optional. We aimed to have 1000 participants across countries to achieve diversity in respondents regarding gender, age, and regional representation. Study details can be found in the GVPS report [1].
There were questions for all participants and a sub-set for self-identified HCP. We asked all participants awareness and usage questions regarding sexual health (SH) and reproductive health (RH) apps: (1) 'have you heard of' (responses: I don't know what that is; yes, but I don't know how to access; yes, I know what this is, and I know where to access), (2) 'have you used' (responses: I don't need this/not relevant; no, I have not used; yes, I have used in the past three months; yes, I have used), and (3)'what are the top factors for deciding to use' (responses: privacy and confidentiality, lack of judgment, empowerment, confidence, accessibility). We also asked HCP respondents their experience providing referrals/information regarding SH and RH apps ('have you provided a referral or information about these services to your patients/clients', responses: no, yes, it is not available where I live, it is not related to my job) and selfperceived confidence and information/training needs ('how confident and informed do you feel about these services', responses: I need training to provide this service, I need more information, I feel confident and informed). The survey also provided an opportunity for HCP participants to provide open-ended feedback regarding SRH self-care interventions (Is there anything you would like to share with us?).

Results
There were 825 participants: 360 participants identified as HCP and 465 participants did not identify as HCP (lay persons). Table 1 details participant socio-demographic characteristics. Locations of residence across WHO regions and participant age were diverse (see Table 2). Full details regarding survey implementation and participants may be found in the GPVS report [1]. Responses are detailed in Table 3 and summarized below.

Sexual health (SH) mobile apps
Less than half of participants (HCP: 47.3%; lay persons: 41.7%) reported that they knew what SH apps were and how to access; approximately one-tenth reporting ever using them (HCP: 12.2%; lay persons: 12.7%). Approximately one-third (34.3%) of HCP participants had provided a referral/information to their clients about SH apps. HCP that reported they or their partner had ever used a SH app were more likely to have referred an SH app to their clients (chi-square (1, n = 292) = 41.18, p < 0.0001). While 40.8% of HCP felt confident and informed about SH apps, nearly half (47.4%) reported needing more information and 15.6% training.

Reproductive health (RH) mobile apps
Just over half of participants (HCP: 56.1%; lay persons: 53.8%) reported knowing what a RH app was and how to access, and approximately one-fifth (HCP: 17.6%, lay persons: 20.4%) had ever used one. While 42.6% of HCPs felt confident and informed about RH apps, 45.7% needed more information and 15.1% more training. One-third of HCP (n = 106; 35.2%) had provided  a RH app referral/information to clients. HCP that reported that they or their partner had ever used a RH app were more likely to have referred an RH app to their client (chi-square (1, n = 289) = 21.92, p < 0.0001). Table 4 reports qualitative responses by HCP participants about SRH apps. Themes included the importance of (a) security and confidentiality; (b) SRH apps in increasing access to information for underserved groups; (c) community engagement to increase SRH digital service awareness; (d) SRH apps for advancing health; and (e) recommendations for online SRH mobile apps training.

Discussion
Overall, GVPS findings signal widespread awareness of SRH health apps, but lower uptake. As HCP reported interest in providing clients with SRH app information, it is important to address barriers to their referrals to clients. We also report valuable information on HCP training needs and preferences for integrating SRH apps into their practice. As HCP's use of SH/RH apps was associated with a much higher likelihood of client referrals, HCP trainings could involve downloading and testing SH/RH apps. Qualitative findings aligned with the WHO Classification of Digital Health Interventions [4]. For instance, perceptions that SRH apps may be particularly helpful for youth and persons in rural areas align with classification 1.1.2 regarding targeted health information to clients based on demographics [4]. Discussions regarding SRH apps for community mobilization aligns with classification 1.3.1 regarding peer groups for clients [4]. Feedback from HCP on how digital technology can be used to link clients to health facilities and community workers is congruent with 2.4.2, remote monitoring of client health or diagnostic data by the provider. The importance of SRH apps alongside regular reminders for health care visits aligns with 1.1.3, targeted alerts, and reminders to clients. SRH apps that facilitate clients entering data to receive test results maps onto 1.4.2, self monitoring of diagnostic data. Finally, HCP recommendations for online training on SRH mobile apps are relevant for 2.8.1, training content to healthcare providers.
There are study limitations. Non-random sampling and limited survey languages limit the generalizability of findings. While we included 825 participants from 112 countries, small sample sizes per country and region preclude region-specific analyses. Due to online recruitment, the survey may disproportionately include persons with computer/internet access, persons already using digital technologies, and persons connected to SRH listservs. Despite these limitations, this is the largest to date survey on self-care SRHR interventions and generated perspectives from lay persons and HCP to inform future representative studies.
To support the increased access and use of quality digital technologies linked to self-care interventions for SRHR and healthcare systems, community mobilization and online HCP training emerged as important considerations. Digital tools can be leveraged to train HCP to support SRH mobile app usage among clients. Table 3. Awareness, uptake, and training needs for sexual and reproductive health mobile apps from participants in a global values and preferences survey.

Disclosure statement
The authors declare that they have no conflict of interest.

Ethics and consent
The Research Ethics Board at the University of Toronto provided research ethics approval for this study. Training on mobile app usage in rendering services. (Ghana) Online training courses, links to valid sources of information like the WHO (Kenya) Training on self testing kits and how to use reproductive health mobile apps (Kenya) Online tutorial by healthcare providers (UK) and online workshops (Uruguay)