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Young women from the low-middle-income country of Lesotho in southern Africa frequently report limited knowledge regarding sexual and reproductive health issues and engage in risky sexual behaviors. The purpose of this study is to describe the adaptation of an evidence-based conversational agent system for implementation in Lesotho and provide qualitative data pertaining to the success of the said adaptation. An embodied conversational agent system used to provide preconception health advice in the United States was clinically and culturally adapted for use in the rural country of Lesotho in southern Africa. Inputs from potential end users, health leaders, and district nurses guided the adaptations. Focus group discussions with young women aged 18-28 years who had used the newly adapted system renamed \"Nthabi\" for 3-4 weeks and key informant interviews with Ministry of Health leadership were conducted to explore their views of the acceptability of the said adaptation. Data were analyzed using NVivo software, and a thematic content analysis approach was employed in the study. A total of 33 women aged 18-28 years used Nthabi for 3-4 weeks; eight (24.2%) of them were able to download and use the app on their mobile phones and 25 (75.8%) of them used the app on a tablet provided to them. Focus group participants (  = 33) reported that adaptations were culturally appropriate and provided relevant clinical information. The participants emphasized that the physical characteristics, personal and non-verbal behaviors, utilization of Sesotho words and idioms, and sensitively delivered clinical content were culturally appropriate for Lesotho. The key informants from the Ministry leadership (  = 10) agreed that the adaptation was successful, and that the system holds great potential to improve the delivery of health education in Lesotho. Both groups suggested modifications, such as using the local language and adapting Nthabi for use by boys and young men. Clinically tailored, culturally sensitive, and trustworthy content provided by Nthabi has the potential to improve accessibility of sexual and reproductive health information to young women in the low-middle-income country of Lesotho.

Background Improving the health of women before pregnancy and throughout a woman’s lifespan could mitigate disparities and improve the health and wellbeing of women, infants and children. The preconception period is important for reducing health risks associated with poor maternal, perinatal and neonatal outcomes, and eliminating racial and ethnic disparities in maternal and child health. Low cost health information technology interventions provided in community-based settings have the potential to reach and reduce disparities in health outcomes for socially disadvantaged, underserved and health disparity populations. These interventions are particularly important for Black and African American women who have a disproportionate burden of pregnancy-related complications and infant mortality rates compared to any other racial and ethnic group in the U.S. Methods This is a hybrid type II implementation-effectiveness cohort study aimed at evaluating appropriateness, acceptability and feasibility implementation outcomes, while also systematically examining the clinical effectiveness of a preconception care (PCC) intervention, the Gabby System, for Black and African American women receiving health services in community-based sites. The intervention will be implemented in six Community Health Centers and six Healthy Start programs across the U.S. Each study site will recruit and enroll 25–50 young Black and African American women who will participate in the intervention for a 6-month period. Appropriateness, acceptability and feasibility of implementing the PCC intervention will be assessed using: 1) Qualitative data derived from individual interviews with Gabby System end-users (clients and patients) and site staff; and, 2) Quantitative data from staff surveys, Gabby System usage and uptake. Aggregate health risk and utilization measures collected directly from the Gabby server will be used to examine the effectiveness of the Gabby System on self-reported behavior change. Discussion This study will examine implementation outcomes and clinical effectiveness of an evidence-based PCC intervention for Black and African American women receiving services in Healthy Start programs and Community Health Centers. Contextual factors that influence uptake and appropriate implementation strategies will be identified to inform future scalability of the intervention. Trial registration ClinicalTrials.gov NCT04514224 . Date of registration: August 14, 2020. Retrospectively Registered.

Young women in Lesotho face myriad sexual and reproductive health problems. There is little time to provide health education to women in low-resource settings with critical shortages of human resources for health. This study aims to determine the acceptability and usability of a conversational agent system, the Nthabi health promotion app, which was culturally adapted for use in Lesotho. We conducted a descriptive quantitative study, using a 22-item Likert scale survey to assess the perceptions of the usability and acceptability of 172 young women aged 18-28 years in rural districts of Lesotho, who used the system on either smartphones or tablets for up to 6 weeks. Descriptive statistics were used to calculate the averages and frequencies of the variables. χ tests were used to determine any associations among variables. A total of 138 participants were enrolled and completed the survey. The mean age was 22 years, most were unmarried, 56 (40.6%) participants had completed high school, 39 (28.3%) participants were unemployed, and 88 (63.8%) participants were students. Respondents believed the app was helpful, with 134 (97.1%) participants strongly agreeing or agreeing that the app was \"effective in helping them make decisions\" and \"could quickly improve health education and counselling.\" In addition, 136 (98.5%) participants strongly agreed or agreed that the app was \"simple to use,\" 130 (94.2 %) participants reported that Nthabi could \"easily repeat words that were not well understood,\" and 128 (92.7%) participants reported that the app \"could quickly load the information on the screen.\" Respondents were generally satisfied with the app, with 132 (95.6%) participants strongly agreeing or agreeing that the health education content delivered by the app was \"well organised and delivered in a timely way,\" while 133 (96.4%) participants \"enjoyed using the interface.\" They were satisfied with the cultural adaptation, with 133 (96.4%) participants strongly agreeing or agreeing that the app was \"culturally appropriate and that it could be easily shared with a family or community members.\" They also reported that Nthabi was worthwhile, with 127 (92%) participants reporting that they strongly agreed or agreed that they were \"satisfied with the application and intended to continue using it,\" while 135 (97.8%) participants would \"encourage others to use it.\" Participants aged 18-24 years (vs those aged 25-28 years) agreed that the \"Nthabi app was simple to use\" (106/106, 100% vs 30/32, 98.8%; P=.01), and agreed that \"the educational content was well organised and delivered in a timely way\" (104/106, 98.1% vs 28/32, 87.5%; P=.01). These results support further study of conversational agent systems as alternatives to traditional face-to-face provision of health education services in Lesotho, where there are critical shortages of human resources for health. ClinicalTrials.gov NCT04354168; https://www.clinicaltrials.gov/study/NCT04354168.

BackgroundYoung women worldwide face problems like unwanted pregnancy and sexually transmitted infections. Providing sexual and reproductive health education to young women in low- and middle-income countries is a priority. It is unknown if using digital health interventions to deliver health education is effective in resource-constrained settings.MethodsWe conducted an interventional trial among young women in the low–middle-income country of Lesotho to test the impact of the conversational agent system (“Nthabi”) designed to deliver sexual and reproductive health information on either a smartphone or tablet for up to 6 weeks. We measured participant’s knowledge before and after the discussion of family planning, folic acid use, and healthy eating. The main outcome measure was a change in knowledge among participants in these three topic areas. The number of correct pre- and post-test responses was compared using generalized linear models that directly estimated the proportions and percentages of correct responses.ResultsWe recruited 172 young women (mean age 22.5 years, 91% unmarried, 69% completed high school, 23% unemployed, 66% students) to use Nthabi on a mobile phone (11.6%) or loaned tablet device (88.4%). The mean number of interactions with Nthabi was 8.6. Family planning was chosen to be discussed by 82 of the 172 participants (52.2%), and of those, 49 (31.2%) completed the content on this topic, and 26 (16.6) completed the post-test. For the 11 questions about family planning, the total percent of correct responses increased from 85.5% (796 total responses) on the pre-test to 89.9% (320 responses) on the post-test (p = 0.0233). Folic acid use was chosen to be discussed by 74 (47.1%) of 172 participants, and of those, 27 (17.7%) completed the content on this topic, and all 27 (17.7%) completed the post-test. For the 5 questions about folic acid use, the total percent of correct responses was 45.3% (181 total responses) on the pre-test and 71.6% (111 responses) on the post-test (p < 0.0001).ConclusionsThe Nthabi conversational agent system increased knowledge of family planning methods and folic acid use among young women in Lesotho. Digital health interventions like Nthabi have the potential to offer new ways to deliver reproductive health information.Trial registrationClinicalTrials.gov registration April 20, 2020; ID: NCT04354168.

A preconception Virtual Patient Advocate (VPA) called “Gabby” supported African-American women to decrease their preconception health risks and may be a scalable resource to increase women’s access to preconception care. Aims were to assess the acceptability of a preconception VPA in women living in Australia and document the changes required to adapt Gabby to suit an Australian context. Taking a descriptive qualitative approach, nonpregnant female participants (n = 31), aged 18–45 years, living in metropolitan and regional Victoria, Australia interacted with Gabby. Focus groups (n = 7) that gathered participants’ perspectives of their experience with Gabby ran in July–August 2019 before being transcribed verbatim and thematically analyzed. Six interrelated themes and 12 subthemes were identified. Participants found VPAs to be an acceptable provider of health information with potential to increase women’s access preconception health advice. Gabby was considered to be trustworthy and was able to develop rapport with participants in a relatively short time. Context-specific, relevant, tailored and trustworthy information and advice were considered more important that Gabby’s physical appearance. Participants had strong opinions about potential technological advancements (e.g., reminders and rewards) and addressing navigation issues to increase Gabby’s acceptability. Participants envisaged that they would use Gabby for readily available and evidence-based information before seeking advice from a health professional if required. Overall, the concept VPAs to provide preconception advice and Gabby were acceptable to participants. Future development of VPAs, Gabby, and other online technology-based resources should consider women’s high expectations of the online health information they choose to interact with.