Palmer Melissa J, Henschke Nicholas, Villanueva Gemma, Maayan Nicola, Bergman Hanna, Glenton Claire, Lewin Simon, Fønhus Marita S, Tamrat Tigest, Mehl Garrett L, Free Caroline
Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
Cochrane Response, Cochrane, London, UK.
Cochrane Database Syst Rev. 2020 Jul 14;8(8):CD013680. doi: 10.1002/14651858.CD013680.
The burden of poor sexual and reproductive health (SRH) worldwide is substantial, disproportionately affecting those living in low- and middle-income countries. Targeted client communication (TCC) delivered via mobile devices (MD) (TCCMD) may improve the health behaviours and service use important for sexual and reproductive health.
To assess the effects of TCC via MD on adolescents' knowledge, and on adolescents' and adults' sexual and reproductive health behaviour, health service use, and health and well-being.
In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.
We included randomised controlled trials of TCC via MD to improve sexual and reproductive health behaviour, health service use, and health and well-being. Eligible comparators were standard care or no intervention, non-digital TCC, and digital non-targeted communication.
We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second. We have presented results separately for adult and adolescent populations, and for each comparison.
We included 40 trials (27 among adult populations and 13 among adolescent populations) with a total of 26,854 participants. All but one of the trials among adolescent populations were conducted in high-income countries. Trials among adult populations were conducted in a range of high- to low-income countries. Among adolescents, nine interventions were delivered solely through text messages; four interventions tested text messages in combination with another communication channel, such as emails, multimedia messaging, or voice calls; and one intervention used voice calls alone. Among adults, 20 interventions were delivered through text messages; two through a combination of text messages and voice calls; and the rest were delivered through other channels such as voice calls, multimedia messaging, interactive voice response, and instant messaging services. Adolescent populations TCCMD versus standard care TCCMD may increase sexual health knowledge (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.23 to 1.71; low-certainty evidence). TCCMD may modestly increase contraception use (RR 1.19, 95% CI 1.05 to 1.35; low-certainty evidence). The effects on condom use, antiretroviral therapy (ART) adherence, and health service use are uncertain due to very low-certainty evidence. The effects on abortion and STI rates are unknown due to lack of studies. TCCMD versus non-digital TCC (e.g. pamphlets) The effects of TCCMD on behaviour (contraception use, condom use, ART adherence), service use, health and wellbeing (abortion and STI rates) are unknown due to lack of studies for this comparison. TCCMD versus digital non-targeted communication The effects on sexual health knowledge, condom and contraceptive use are uncertain due to very low-certainty evidence. Interventions may increase health service use (attendance for STI/HIV testing, RR 1.61, 95% CI 1.08 to 2.40; low-certainty evidence). The intervention may be beneficial for reducing STI rates (RR 0.61, 95% CI 0.28 to 1.33; low-certainty evidence), but the confidence interval encompasses both benefit and harm. The effects on abortion rates and on ART adherence are unknown due to lack of studies. We are uncertain whether TCCMD results in unintended consequences due to lack of evidence. Adult populations TCCMD versus standard care For health behaviours, TCCMD may modestly increase contraception use at 12 months (RR 1.17, 95% CI 0.92 to 1.48) and may reduce repeat abortion (RR 0.68 95% CI 0.28 to 1.66), though the confidence interval encompasses benefit and harm (low-certainty evidence). The effect on condom use is uncertain. No study measured the impact of this intervention on STI rates. TCCMD may modestly increase ART adherence (RR 1.13, 95% CI 0.97 to 1.32, low-certainty evidence, and standardised mean difference 0.44, 95% CI -0.14 to 1.02, low-certainty evidence). TCCMD may modestly increase health service utilisation (RR 1.17, 95% CI 1.04 to 1.31; low-certainty evidence), but there was substantial heterogeneity (I = 85%), with mixed results according to type of service utilisation (i.e. attendance for STI testing; HIV treatment; voluntary male medical circumcision (VMMC); VMMC post-operative visit; post-abortion care). For health and well-being outcomes, there may be little or no effect on CD4 count (mean difference 13.99, 95% CI -8.65 to 36.63; low-certainty evidence) and a slight reduction in virological failure (RR 0.86, 95% CI 0.73 to 1.01; low-certainty evidence). TCCMD versus non-digital TCC No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may modestly increase in service attendance overall (RR: 1.12, 95% CI 0.92-1.35, low certainty evidence), however the confidence interval encompasses benefit and harm. TCCMD versus digital non-targeted communication No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may increase service utilisation overall (RR: 1.71, 95% CI 0.67-4.38, low certainty evidence), however the confidence interval encompasses benefit and harm and there was considerable heterogeneity (I = 72%), with mixed results according to type of service utilisation (STI/HIV testing, and VMMC). Few studies reported on unintended consequences. One study reported that a participant withdrew from the intervention as they felt it compromised their undisclosed HIV status.
AUTHORS' CONCLUSIONS: TCCMD may improve some outcomes but the evidence is of low certainty. The effect on most outcomes is uncertain/unknown due to very low certainty evidence or lack of evidence. High quality, adequately powered trials and cost effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCC delivered by mobile devices. Given the sensitivity and stigma associated with sexual and reproductive health future studies should measure unintended consequences, such as partner violence or breaches of confidentiality.
全球不良性与生殖健康（SRH）负担沉重，对低收入和中等收入国家人群的影响尤为严重。通过移动设备（MD）进行的针对性客户沟通（TCC）（TCCMD）可能会改善对性与生殖健康至关重要的健康行为和服务利用情况。
评估通过MD进行的TCC对青少年知识水平、青少年及成年人的性与生殖健康行为、健康服务利用以及健康和幸福感的影响。
2017年7月/8月，我们检索了五个数据库，包括Cochrane对照试验中心注册库、MEDLINE和Embase。我们还检索了两个试验注册库。2019年7月进行了检索更新，潜在相关研究正在等待分类。
我们纳入了通过MD进行TCC以改善性与生殖健康行为、健康服务利用以及健康和幸福感的随机对照试验。合格的对照为标准护理或无干预、非数字TCC以及数字非针对性沟通。
我们采用了Cochrane推荐的标准方法程序，尽管数据提取和偏倚风险评估仅由一人进行，并由另一人进行交叉核对。我们分别针对成人和青少年人群以及每次比较呈现了结果。
我们纳入了40项试验（成人人群中有27项，青少年人群中有13项），共有26,854名参与者。青少年人群中的试验除一项外均在高收入国家进行。成人人群中的试验在一系列高收入到低收入国家进行。在青少年中，9项干预仅通过短信进行；4项干预测试了短信与其他沟通渠道（如电子邮件、多媒体短信或语音通话）的组合；1项干预仅使用语音通话。在成年人中，20项干预通过短信进行；2项通过短信和语音通话的组合进行；其余通过其他渠道（如语音通话、多媒体短信、交互式语音应答和即时通讯服务）进行。青少年人群TCCMD与标准护理相比TCCMD可能会增加性健康知识（风险比（RR）1.45，95%置信区间（CI）1.23至1.71；低确定性证据）。TCCMD可能会适度增加避孕措施的使用（RR 1.19，95% CI 1.05至1.35；低确定性证据）。由于证据确定性极低，对避孕套使用、抗逆转录病毒疗法（ART）依从性和健康服务利用的影响尚不确定。由于缺乏研究，对堕胎率和性传播感染（STI）率的影响未知。TCCMD与非数字TCC（如宣传册）相比由于缺乏此比较的研究，TCCMD对行为（避孕措施使用、避孕套使用、ART依从性）、服务利用、健康和幸福感（堕胎率和STI率）的影响未知。TCCMD与数字非针对性沟通相比由于证据确定性极低，对性健康知识、避孕套和避孕措施使用的影响尚不确定。干预可能会增加健康服务利用（性传播感染/艾滋病毒检测就诊率，RR 1.61，95% CI 1.08至2.40；低确定性证据）。该干预可能有助于降低STI率（RR 0.61，95% CI 0.28至1.33；低确定性证据），但置信区间包含了益处和危害。由于缺乏研究，对堕胎率和ART依从性的影响未知。由于缺乏证据，我们不确定TCCMD是否会导致意外后果。成人人群TCCMD与标准护理相比对于健康行为，TCCMD可能会在12个月时适度增加避孕措施的使用（RR 1.17，95% CI 0.92至1.48），并可能降低重复堕胎率（RR 0.68，95% CI 0.28至1.66），尽管置信区间包含了益处和危害（低确定性证据）。对避孕套使用的影响尚不确定。没有研究测量此干预对STI率的影响。TCCMD可能会适度增加ART依从性（RR 1.13，95% CI 0.97至1.32，低确定性证据，标准化均值差0.44，95% CI -0.14至1.02，低确定性证据）。TCCMD可能会适度增加健康服务利用率（RR 1.17，95% CI 1.04至1.31；低确定性证据），但存在大量异质性（I² = 85%），根据服务利用类型（即性传播感染检测就诊；艾滋病毒治疗；自愿男性包皮环切术（VMMC）；VMMC术后随访；堕胎后护理）结果不一。对于健康和幸福感结果，对CD4细胞计数可能几乎没有或没有影响（均值差13.99，95% CI -8.65至36.63；低确定性证据），病毒学失败略有降低（RR 0.86，95% CI 0.73至1.01；低确定性证据）。TCCMD与非数字TCC相比没有研究将STI率、避孕套使用、ART依从性、堕胎率或避孕措施使用作为此比较的结果。TCCMD总体上可能会适度增加服务就诊率（RR：1.12，95% CI 0.92 - 1.35，低确定性证据），然而置信区间包含了益处和危害。TCCMD与数字非针对性沟通相比没有研究将STI率、避孕套使用、ART依从性、堕胎率或避孕措施使用作为此比较的结果。TCCMD总体上可能会增加服务利用率（RR：1.71，95% CI 0.67 - 4.38，低确定性证据），然而置信区间包含了益处和危害，且存在相当大的异质性（I² = 72%），根据服务利用类型（性传播感染/艾滋病毒检测和VMMC）结果不一。很少有研究报告意外后果。一项研究报告称，一名参与者退出了干预，因为他们觉得这危及了他们未公开的艾滋病毒感染状况。
TCCMD可能会改善一些结果，但证据的确定性较低。由于证据确定性极低或缺乏证据，对大多数结果的影响尚不确定/未知。需要高质量、有足够样本量的试验和成本效益分析，以可靠地确定通过移动设备进行的TCC的效果和相对益处。鉴于性与生殖健康相关的敏感性和污名化，未来的研究应测量意外后果，如伴侣暴力或保密性的泄露。
