Nigeria has one of the largest adolescent populations in the world. Over 25% of the population are adolescents, i.e, ages 10 to 19 (1). Adolescence is a period characterized by physiological, psychological and social changes that expose individuals to unhealthy sexual behaviours, placing them at risk for sexual and reproductive health problems such as teenage pregnancies, unsafe abortions, STIs, HIV/AIDS and other life-threatening problems (2). Adolescent sexual and reproductive health (ASRH) is a growing global concern because of the high rates of unhealthy sexual behaviour among this population group. About half of the adolescent population in Nigeria is sexually active, majority of whom do not practice safe sex, with dire consequences for their health and future (3). HIV prevalence among adolescents in Nigeria is estimated to be 3.5%, the highest in West and Central Africa (4) and the prevalence of unintended pregnancy and unsafe abortions have been estimated to be 26.6% and 21.7% respectively (5). Also, a study conducted in Calabar found that unwanted pregnancy was responsible for 11% of school dropouts, affecting the girls’ chances at economic prosperity (6). The myriad of challenges facing ASRH in Nigeria is a pointer to the limited use of SRH services by adolescents due to barriers such as lack of youth-friendly and comprehensive SRH services at many health facilities, shortage of trained personnel, and provider attitudes that are not friendly to adolescents (7).
The proliferation of cell phones across the globe and in Nigeria has ushered in the use of mobile technology for health service delivery (mHealth). Healthcare can now be delivered through digital channels such as SMS, phone calls, internet, mobile apps and even video messaging. Young people represent the largest proportion of mobile phone users globally. In Nigeria, two-thirds of 14 to 18 year olds in peri-urban areas own mobile phones while others have shared access to a mobile phone with their parents, siblings or friends (8). Text messaging is the most popular form of mobile communication among young people (9). Global research suggests that providing SRH information via mobile phones is appealing to young people and can substantially influence their SRH outcomes (9).
This article will discuss the potential of mHealth to increase adolescents’ access to SRH services in Nigeria, the challenges involved and possible mitigating factors.
Potential of mHealth for ASRH
mHealth has enormous potential to increase adolescents’ access to SRH services by addressing barriers to receiving SRH information and services. Specifically, it can help overcome most of the socio-cultural barriers adolescents face, such as provider prejudice, stigmatization, fear of refusal, lack of privacy, confidentiality and embarrassment to seek information on SRH topics (10). In Nigeria, mHealth can provide a suitable, cost-effective and efficient channel for engaging adolescents on a wide range of SRH topics in a safe manner.
Different mHealth platforms have been used for delivering ASRH services, including SMS, voice calls, information hotlines, video calls, instant messaging, and emails. However, SMS is reported as the most frequently used (70-80% of the time) because of its low cost and ability to penetrate different socio-economic groups (10,11). Other commonly used platforms include information hotlines, video calls and instant messaging.
Many mHealth interventions have used health promotion messages to facilitate knowledge sharing and behavior change via SMS (9,12). These include “push messaging” where specific information is texted to adolescents on a regular schedule and “on-demand” messaging where adolescents can retrieve SRH content via a question-and-answer platform or text SRH questions to health professionals (6,9,10). The SMS content provides information on a range of SRH topics such as reproductive anatomy, pregnancy, STIs, HIV/AIDS, contraception and safe sex. These methods have been found to be acceptable to many adolescents and indeed were associated with increased sexual health knowledge and awareness, and lower rates of unprotected sex and STIs among recipients of the messages (11,13).
mHealth has also been used to link users to needed SRH services such as family planning counselling and services, medical abortions, post abortion care, HIV testing and treatment. For example, MSI in Ethiopia piloted an electronic voucher for SRH services to increase family planning use among young people. The vouchers were sent directly to people’s phones as opposed to the regular paper vouchers. Within a 6-month period, 92% of the vouchers had been redeemed by individuals aged 15 to 29, signifying an increase in family planning uptake(9). Similarly, Sydani Initiative piloted a mobile technology intervention to increase contraceptive uptake among young people in an IDP camp via provision of SRH SMS and a toll-free line in FCT, Nigeria. Virtual family planning providers (VFPPs) counselled and encouraged clients via phone calls to receive family planning services at local clinics. This intervention nearly quadrupled contraceptive uptake among this population group (14).
Challenges to effective use of mHealth interventions
Despite the potential that mHealth has for increasing adolescents’ access to SRH services, it presents some challenges. First, many areas lack efficient telecommunications infrastructure resulting in poor connectivity, thus compromising the continuity, reach and quality of mHealth interventions. Ensuring these structures are in place, especially in rural communities is crucial to the success of mHealth. Secondly, there is currently a lack of sustainable financing for mHealth interventions in Nigeria and this limits the continuity of mHealth interventions, especially for ASRH (15). Therefore, it is crucial for the government to improve financial commitment for mHealth, especially for SRH interventions that have demonstrated significant impact. Also, maintaining data security and privacy remains a major risk of mHealth interventions. Since many adolescents share mobile phones with other family members, they may have difficulty shielding sensitive information from other family members. Moreover, breech of data security can leak highly sensitive client information to the wrong quarters with grave consequences for the clients. Therefore, in designing mHealth interventions, context-specific risk reduction strategies should be considered (12). Finally, mHealth interventions will leave out a proportion of adolescents- those who lack access to mobile phones. Many adolescents, especially those under age 15, still lack access to mobile phones and thus will be unable to access mHealth interventions. Therefore, provision of adolescent friendly SRH services in addition to mHealth will ensure that no key population is left out of accessing ASRH services.
In conclusion, mHealth technology, especially SMS has huge potential to increase adolescents’ access to SRH services and improve ASRH outcomes in Nigeria in an acceptable, and cost-effective manner. However, some challenges may prevent its effectiveness. These include poor telecommunications service, lack of sustainable financing concerns around data privacy and security and lack of mobile phones by many adolescents in the country. Therefore, when considering the use of mHealth for ASRH services, deliberate measures need to be put in place to avoid some of these challenges. In addition, sustainable financing for mHealth and provision of adolescent-friendly health centers will help to buffer the negative effects of mHealth and should also be considered as we rethink ASRH services provision through mHealth in Nigeria.
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