Zvatinoda! (What we want!): Increasing demand and uptake of sexual and reproductive health services by young people in Zimbabwe

Over 3000 adolescents die every day due to largely avoidable causes. Most of these deaths occur in low- and middle-income countries. Use of appropriate preventive and treatment services could prevent many of these deaths but young people are less likely than adults or younger children to access healthcare. Risky sexual practices and reluctance to seek medical care in adolescence (10-19 years) and young adulthood (20-24 years) will affect long-term sexual and reproductive health. Adolescence and young adulthood, therefore, provide a window of opportunity for establishing healthy behaviours which can improve health and well-being later in life. However, not all health services are youth friendly and we don't know enough about the kinds of services that young people (YP) want and what would, for example, encourage them to attend a clinic.
Research shows that mobile health interventions can improve knowledge, attitudes and behaviours among young people, but we don't know whether mobile health interventions can increase use of health services. We will work with YP to develop and test the feasibility of an intervention that will improve health service use in Mutare District, Zimbabwe. The Zvatinoda! intervention will involve 'Auntie' moderated discussion groups for YP and feedback to service providers on how to make sexual and reproductive health (SRH) services more youth-friendly. We will address the following questions:

1. Why are YP not accessing SRH services and which factors are malleable and have the greatest scope for change?

2. What is the most acceptable and feasible Zvatinoda! discussion group format?
We will conduct individual and group discussions with YP to find out more about their lives. We will explore whether using a technology platform e.g. WhatsApp, SMS, is a good way to interact with YP about their health. We will ask YP to help us to design the discussion group component of the intervention. Discussion groups will provide information, peer support, and be led by a 'mobile Auntie or Uncle' - a culturally appropriate mentor who can provide guidance and problem solve challenges to uptake of health services.

3. What is the most acceptable and feasible health facility feedback format?
We will hold discussions with health system and community members to find out more about the YP's health needs and the facilitators and barriers to youth friendly health service provision. We will explore the potential for feedback on YP's needs and preferences to inform health service design. We will ask service providers to help us to design the feedback component of the intervention.

4. Could there be any negative consequences of the intervention and how could we mitigate against such events?

5. Is it feasible to implement the Zvatinoda! intervention among YP aged 16-24 living in the geographical catchment area of 2 primary care clinics?
We will analyse the conversations that take place on the Zvatinoda! groups. We will share information on YPs' needs and preferences with service providers and community members and encourage them to use this information to improve the quality and youth-friendliness of their services. To understand how our intervention worked or didn't work, we will talk to participating YP, community members and health care providers. We will also get their suggestions on how to improve the intervention. We will consider the resources that would be needed for potential sustainability and scale-up.

6. How would we measure the effectiveness of the Zvatinoda! mHealth intervention in improving service provider practice and attitudes, and increasing use of health services by YP?
We will identify the most appropriate health outcomes for the main evaluation study, and the most appropriate measures of youth engagement, satisfaction with health services, and health worker attitudes. We will explore the feasibility of using routine health service records to monitor health service uptake by YP.

Uptake and quality of health services for adolescents and young adults (YP) is often poor, leading to preventable morbidity and mortality. Systematic reviews of adolescent interventions suggest mobile health strategies improve some YP outcomes but evidence of their effectiveness for improving health-seeking behaviour is limited. Building on evidence that physical support groups for those living with HIV can lead to improvements in medication adherence, we propose mobile phone discussion groups as a promising and novel approach to increase service uptake. We will develop and test an innovative approach, Zvatinoda! (What we want!) which aims to improve YP uptake of sexual and reproductive health services in Mutare District, Zimbabwe. Formative research and a participatory co-design workshop with YP and stakeholders will inform intervention design. Discussion groups for YP will provide information, peer support, and be led by a culturally appropriate mentor who can provide guidance and problem solve challenges to service uptake. Discussion content will be extracted and thematically analysed, and YP's needs and preferences shared with stakeholders to guide the improvement of services. We will conduct a 4-month feasibility study among 16-24 year olds living in the catchment of two health facilities in Mutare District. Findings will inform the main trial protocol.
Research questions:
1.Why are YP not accessing health services? Which factors are malleable and have the greatest scope for change?
2.What are the most acceptable and feasible discussion group and health facility feedback formats?
3.What negative consequences might the intervention have and how can we mitigate against such events?
4.Is it feasible to implement the intervention among YP in the geographical catchment area of 2 primary care clinics?
5.How could we measure the effectiveness of Zvatinoda! on improving service provider practice and attitudes, and increasing use of health services by YP?

Youth: The immediate benefit of this research will be to adolescents and young adults living in Mutare District in Zimbabwe who participate in this study. They will benefit from increased information and support from their peers and the mobile auntie who moderates the discussion groups. If discussion groups are not an appropriate way of supporting young people to identify their health needs and access health services, then there will be limited immediate benefit of this research. However, the knowledge gained during the project will inform the improvement of the content and/or the implementation of youth friendly health services in this area. The small number of adolescents and young people (YP) who participate in our research will gain an understanding of research, and may benefit from an increased sense of empowerment.
Families and the wider local community: Any benefit for YP in terms of improved health and well-being may benefit their partners and families by improving trust and/or engagement with healthcare services, and by improving overall well-being in the family. Short-term community-wide benefits would be minimal but if the intervention were to be implemented on a larger scale (based on the results of this work) then we would anticipate economic and societal impacts because of a more effective public health service, and improved health and quality of life for YP and their families.
Primary health care clinics: This research will benefit primary health care clinics by engaging with YP who are slipping through the net of existing services, and by improving knowledge on how and when to interact with YP to improve the uptake of preventive and treatment sexual and reproductive health services. In the longer-term feedback from YP facilitate a more efficient and effective health service, and reduce the workload of clinic staff.
Policy makers/programmers: This study is designed to inform practice, and we anticipate that the findings will be used to inform the design and implementation of youth-friendly health services. The findings may also be transferrable to other population groups. In addition to data on the acceptability, feasibility and impact of the Zvatinoda! intervention, we will also be able to provide policy makers/programmers with data on the marginal cost of this approach. This intervention, if effective, would contribute to the international and national goal of universal healthcare.
International public health community: This research is aligned with relevant international and national commitments on improving the uptake of health services by YP, and by exploring the use of mhealth within programmes and the active involvement of the target audience in the design of interventions. The results will be of interest to other regions and countries who are considering implementing mHealth or participatory interventions to improve the health of YP.
Academics & other collaborative staff: There is a paucity of research data on adolescents worldwide, as informed consent requirements often deter researchers from including those <18 years of age. This research will advance our understanding of the acceptability and feasibility of mHealth and participatory interventions among adolescents in resource-limited settings, and the feasibility of engaging and interacting with YP through moderated discussion groups. The findings on the use of the selected technology platform (to be decided following formative research) and the success of feedback to health facility staff will be of interest to academics working in other disease areas. The project coordinator who will co-ordinate the study at OPHID will have several capacity building opportunities including a significant on-the-job training and mentoring.