Improving Adolescent Sexual and Reproductive Health: Can Mobile Health Interventions Affect Behavior?

In this issue of Pediatrics, Ybarra et al¹  report the results of a national randomized controlled trial of Girl2Girl, a mobile health (mHealth) intervention aiming to reduce pregnancy rates among lesbian, gay, bisexual, and other sexual minority (LGB+) adolescent girls. Researchers randomly assigned 948 girls aged 14 to 18 to the theory-based, user-informed text messaging intervention versus an attention-matched control group. At trial end, 5 months post-enrollment, those in the Girl2Girl intervention group were significantly more likely to have condom-protected sex and use a birth control method other than condoms.

The study allows us to reflect on the overall impact of mHealth interventions to date because few mHealth interventions have been successful in affecting adolescent sexual and reproductive health (SRH) to the level of Girl2Girl.²  Several reasons likely contribute to this variation. First, behavior change is multifactorial, especially SRH behaviors, affected by a variety of societal and contextual factors. These factors make behavior change challenging to comprehensively address within one intervention. Next, retention rates in mHealth trials can be suboptimal. Adolescents frequently change phone numbers and experience phone disconnections, making patient follow-up challenging and full intervention delivery problematic.³  Lastly, the adoption of any mHealth intervention competes with a host of other priorities for adolescents, such as school, friends, and the incessant pull of checking one’s smartphone. The success of Girl2Girl encourages us to ask why Girl2Girl had a positive impact on adolescent SRH when other mHealth interventions have not.

From my perspective, Girl2Girl distinguishes itself from previous adolescent SRH mHealth studies in three unique ways. First, the very girls whom Girl2Girl aimed to affect were integral to its development. This is an example of user-centered design, a methodology that incorporates the perspective and needs of intended end-users into technology design and is essential for intervention success.⁴  mHealth interventions, especially those that target adolescents, must consider the needs and perceptions of the intended audience so that the intervention will be perceived as easy to use, engaging, and relatable.⁵  Girl2Girl took several steps to understand the needs of LGB+ girls, including focus groups and an advisory board leading to several iterations of the intervention. This type of user-centered design serves as a scaffold for future mHealth interventions, especially those targeting populations in which there is uncertainty of how to address complex behaviors.

Second, Girl2Girl creatively incorporated live peer social support. In Text Buddy, participants were paired anonymously via the Girl2Girl platform and encouraged to provide social support to one another and practice skills taught in the program. This innovative way of connecting LGB+ girls likely fostered new relationships and created a sense of digital support. This is particularly important for adolescents because peer social support can augment perceived self-efficacy and can reinforce new healthy behaviors through observation and modeling.⁶  Despite many of the text messages in Girl2Girl being one-way, which could limit engagement, the intervention creatively included a channel for participants to ask in-the-moment questions, receive just-in-time advice, and, perhaps most importantly, feel heard.

Lastly, researchers recruited participants where adolescents can be found: on social media. Several previous and often less successful mHealth interventions recruited from conventional locations, such as outpatient clinics, religious organizations, and schools.⁷  In recent studies, researchers are thinking outside the box, recruiting from nontraditional locations such as music festivals and crowdsource Web sites.^8,9  In Girl2Girl, participants were recruited from Facebook and Instagram, two leading social media channels. Although social media recruitment, as the authors note, leads to a convenience sample of those who might be more motivated to want to learn and change their behaviors, this study paves a path for future interventions. According to 2018 Pew data, almost all adolescents say they have access to a smartphone, with one-half saying they are online on a near-constant basis.¹⁰  Social media recruitment of younger adolescents, as young as age 14, without parental consent, also highlights how this recruitment methodology can be a safe way to connect with a hard-to-reach population. The Ybarra et al¹  study serves as an example for institutional review boards that are wary of the safety of such recruitment styles.

It is worth noting that, although the authors note no unintended harm from the trial, the extent to which patient confidentiality was maintained is unknown. Many applications exist that allow parents to monitor the smartphones of their children, such as controlling screen time and granting access to text messages. In addition, some LGB+ girls might have not enrolled in the study because of concern for parental oversight. In future mHealth interventions, researchers need to account for this, possibly designing platforms with self-destructing text messages or even engaging parents in joint interventions aiming to build the parent-child dynamic and augment a parent’s ability to have SRH conversations.¹¹ 

Girl2Girl is an example of a carefully conceived mHealth intervention in a time when we need innovative ways to provide engaging, evidence-based sexual education to high-risk teenagers across the United States. Although Girl2Girl has yet to publish implementation data, its 5-month outcomes reveal that Girl2Girl, as a whole, positively affected SRH behavior among girls, minimizing the risk of unintended pregnancy. These findings are both promising for Girl2Girl’s long-term outcomes and for the future of mHealth interventions focusing on adolescents, a population whose unmet unique health needs demand our attention, resources, and creativity.¹² 

LGB+

lesbian, gay, bisexual, and other sexual minority

mHealth

mobile health

SRH

sexual and reproductive health