Perspectives of Adolescents, Parents, Service Providers, and Teachers on Mobile Phone Use for Sexual Reproductive Health Education

Round 1

Reviewer 1 Report

This is a well-written article that reports on the background, methods and findings from research into the acceptability of delivering SRH promotion using mobile phones. 

I have several ethical concerns. I accept that for adolescents under 18 years, it is necessary to get parental consent for participation. Still, I would have expected the adolescents themselves to be asked to give informed consent. I would also have expected more information on the training of researchers in interviewing young people and how the data was handled to protect confidentiality and anonymity. 

However, my main concern is that acceptability does not show that it is practical and will be effective. SRH is about more than teen pregnancy, but as the authors point out, the rate is high in Kenya. The authors also needed to consider, however, which girls get pregnant. According to the 2014 DHS, adolescent girls from the poorest homes are much more likely to have begun childbearing than those from wealthy homes - 26.2% in the lowest wealth quintile compared with 10.2% in the highest wealth quintile. This means that those who are least likely to own or have access to a mobile smartphone most need SRH education. The authors also assume that the main barrier to reducing the adolescent pregnancy rate is education. Still, there is also the issue of access to contraception for girls under 18 years and the stigma associated with contraception use by unmarried women. A further issue is who the fathers are - often, older men entice adolescent girls to have sex in exchange for gifts and money - so-called 'sugar daddies'.

The second problem is that the authors did not use an appropriate research method to judge the ownership of/access to mobile smartphones among adolescents in Kenya. In late 2021 the Communications Authority of Kenya released data on phone ownership in Kenya. This showed that only 36% of adults in rural areas own a mobile phone and 59% in urban areas. Only 44% of registered mobile phones are smartphones.

The conclusion must be, however, acceptable it is to use mHeath for educating young people about SRH; a majority of Kenyan adolescents will not benefit from it. 

Author Response

Dear Review,

I am writing to inform you that we have revised the manuscript based on the points you raised.

Attached please find the detailed response to on how we have addressed each point.

Author Response File: Author Response.doc

Reviewer 2 Report

This paper reports findings of a qualitative study carried out to assess stakeholders’ perspectives on access and use of mobile phones by adolescents for SRH information to inform the design of mHealth interventions in the African contexts.

The authors evaluate if mHealth would facilitate access and use of SRH information by adolescents, from the perspectives of the adolescents, parents, service providers, and teachers. This is a very relevant and interesting topic with different quality data. The paper raises some interesting insights. I have some suggestions for your manuscript.

Title: The title could be more succinct and more focused on the main purpose of the study avoiding acronyms

Keywords: The keywords focus on the main dimensions, but could add to the title, including Comprehensive Sexuality Education and Health Equity

Abstract: The abstract could still be descriptive and shorter if unstructured and written in a single paragraph.

Introduction: The rationale for the study was well explained. However, a more comprehensive and more critical overview of mHealth approaches to sexual and reproductive health diversity of needs across life course and populations in the Sustainable Development Goal era, including the impact of gender inequality on the women’s reproductive rights, would be expected in the introduction. Your introduction would benefit from presenting your operation framework of sexual and reproductive health from a holistic evidence-based, respectful, and positive approach, discussing standards for quality of care including issues of privacy and confidentiality, informed decision making, trained providers, etc.

Some existing works could be useful:

Chandler R, Guillaume D, Parker A, Wells J, Hernandez ND. Developing Culturally Tailored mHealth Tools to Address Sexual and Reproductive Health Outcomes Among Black and Latina Women: A Systematic Review. Health Promot Pract. 2021 Mar 26:15248399211002831. doi: 10.1177/15248399211002831.

Feroz AS, Ali NA, Khoja A, Asad A, Saleem S. Using mobile phones to improve young people sexual and reproductive health in low and middle-income countries: a systematic review to identify barriers, facilitators, and range of mHealth solutions. Reprod Health. 2021 Jan 16;18(1):9. doi: 10.1186/s12978-020-01059-7.

Stephenson R, Gonsalves L, Askew I, Say L; WHO Working Group for Operationalizing Sexual Health. Detangling and detailing sexual health in the SDG era. Lancet. 2017 Sep 9;390(10099):1014-1015. doi: 10.1016/S0140-6736(17)32294-8. Epub 2017 Sep 3. PMID: 28877852.

Waldman L, Stevens M. Sexual and reproductive health and rights and mHealth in policy and practice in South Africa. Reprod Health Matters. 2015 May;23(45):93-102.

Methods: Methods are well described. Consider adding a discussion on the use of FG. Also, provide a rationale for the FGs gendered distribution and age combination (9 to 18 is a wide range).

Research team and reflexivity - What was the influence of the researchers in the data collection process and their skills? How did they present themselves?

Participants’ selection - How were participants selected to be interviewed, how were they approached, and how was the study presented to them?

Setting of data collection - Please detail the setting and the interview guides. Please detail when and how were the FGs and the interviews conducted and comment on the duration and the setting. How was confidentiality ensured along the process of data collection and analysis?

Data analysis – Please consider giving more detail about the coding process. How many data coders coded the data? Were participants asked to provide feedback on the findings?

Results / Discussion: Given the rich data collected, I think there is the potential to do more with the analysis. The analysis seems a little too long and descriptive and could go further. It identifies themes raised by the participants and provides an overview of each one, but it does not really get into them in-depth. It may also be helpful to consider the following questions: How do the themes relate to one another? How do the findings tie into current debates in the field? I would suggest refocusing both the paper results and the abstract to highlight the key contributions of the research.

The authors should present the study limitations and discuss their implications for the results.  

Conclusion: Although results are exploratory, implications of the results should be enlightened with key specific messages for policy and for future investigations.

All the text needs a language revision to improve some typos and grammatical errors.

Author Response

Dear Reviewer, 

I am writing to inform you that we have addressed the points you raised in your review.

Attached please find a detailed response for every point and how it was addressed in the manuscript.

Author Response File: Author Response.doc

Round 2

Reviewer 1 Report

Thank you for trying to address the comments I made on your article. However, you have not addressed the major weakness of your research which is that you do not think through the main barrier to using smartphones for SRH information for adolescents before you did the research. Given the low ownership of smartphones in Kenya in generally and especially among those most likely to benefit from SRH information, the findings on acceptability are of little scholarly interest or benefit for informing policy. 

Author Response

Dear Reviewer,

Thank you for the comments on our article, on behalf of the authors, we would like to inform you that;

• We have reviewed the content to ensure contextualization with previous works on the topic.
• We have revisited our discussion of findings to ensure coherence
• We have reviewed the presentation of results and improved clarity of presentation
• We have reviewed the conclusions to ensure that they are supported by findings

We take note of the fact that we did not think through the main barrier to using smartphones for SRH information for adolescents before we did the research. This was because we intended to document the barriers from the perspectives of the respondents (adolescents, parents, service providers, and teachers), based on the purpose and objectives of the study

Kind Regards