Virtual and essential - adolescent SRHR in the time of COVID-19.

Introduction

COVID-19 has had an unprecedented global impact, causing widespread loss in terms of lives and infections, a paralysis of social networks and health systems, and widespread economic shutdowns. The lockdown measures have caused significant disruptions to essential services and supplies, placing immense pressure on global health systems.

For sexual and reproductive health (SRH) services, interruptions in information and service delivery are estimated to have a serious impact on women’s health and well-being. Studies estimate that disruptions in access to contraceptive services for a period of 6 months, would lead to approximately 47 million women in low- and middle-income countries not being able to meet their contraceptive needs, and potentially 7 million unintended pregnancies in the coming months; or a 10% reduction in use of spacing methods, and 49 million women with unmet need, and 15 million unintended pregnancies.[1,2] It is difficult to find global estimates of the effects on adolescents’ SRH outcomes due to unavailability of meta-data on SRH needs of the young unmarried population, an invisibility largely on account of stigma around pre-marital sexual activity. The absence of adolescent SRH services from “essential” health services during COVID-19 amplifies this undocumented need.

A previous commentary in this journal (December 2019) provocatively discussed the potential role of technology to meet SRH needs of vulnerable groups like adolescents.[3] That commentary could not be more relevant today, as the conjectured role of technology and many of the concerns raised have become unambiguously pertinent and real. Pioneering use of technology in response to the pandemic has created novel situations around delivering health care while adhering to norms around physical distancing. Technological innovations in responding to COVID-19 have ushered in new possibilities in health information and service delivery, that can conceivably be extended to adolescent SRH, both in addressing the immediate adolescent sexual and reproductive health (ASRH) needs and in transforming the paradigms of implementation of ASRH programmes in the long-run. We previously noted challenges associated with digital technologies, such as inequities in digital access, replication of social stratifications and prejudices online, and possibilities of harm and cyber-crimes especially for vulnerable groups. Reflecting further, we revisit the promise and the cautions with respect to technology, requiring more consideration today.

Testing times

Even pre-COVID, adolescents’ open access to SRH information and services has always been socially stigmatised and scrutinised, with restrictions on what sexual and reproductive health and rights (SRHR) support is available and accessible. While COVID-19 has disrupted access for everyone, it has possibly exacerbated the limitations and adversities for vulnerable groups like adolescents more, much of which remains unsubstantiated. A recent report notes the inadequacy of data to properly track the pandemic’s gender effects on the well-being of adolescent girls, among other issues.[4]

However, there is better documentation of the pandemic’s impact on routine reproductive health services. Stringent lockdowns have massively disrupted routine health services, including contraceptive services. Recent estimates for India’s most populous state, Uttar Pradesh, suggest that in the most likely scenario 5.8 million couples would not be able to access contraceptives between March and September 2020, resulting in 421,601 unintended pregnancies, 120,580 live births, 256,338 abortions and 309 maternal deaths. When aggregated globally, this indicates the monumental impact of SRH service disruptions, to which should be added the invisible non-quantifiable impact on adolescents, who even lack the legitimacy or ability to openly seek SRH services.[5]

We can project that these needs for adolescents will not attenuate during COVID-19, and may only amplify due to limited mobility and access to “adolescent-friendly” service channels. Lockdown, limited autonomy, age vulnerability, and lack of adolescent-centric services to begin with, might push adolescents’ sexual health practices and contraceptive needs underground. However, evidence on this remains scant as these are not priority issues being monitored, especially during COVID-19.

COVID-19 has forced nearly 743 million girls out of school globally, raising concerns around long-term impacts on their lives,[6] as closure of formal and non-formal education deprives them of social engagement, with a range of potential negative consequences.[7] They may experience increased sexual and gender-based violence, furthering the need not only for remediation and support services, but also access to emergency contraception and other reproductive health services.[8] With household economies depleted, we may see an increase in child labour and early and forced marriages,[9] with studies estimating an additional four million girls being at risk of child marriage in the next two years,[10] further marginalising an already vulnerable population group.

With significant threats to adolescents’ long-term health and wellbeing, and questions looming around ways to fortify gains and mitigate harm, we ask – Can technology be the “game changer” for adolescent SRH?

Amidst the pandemic, technology has largely provided the means to support recalibration of health systems, service provision and information delivery. Just as digital behaviour change campaigns on hand washing, social distancing and wearing masks have gone viral, and supported pandemic response, can we digitally connect with young people and support their access to SRH information and services that prioritise their needs.

An examination of some cases of innovations signals the immense potential of technology that can be leveraged for ASRHR. The World Health Organisation (WHO) partnered with social media platform TikTok to run an awareness campaign around COVID-19, which is being used by frontline workers to share information and experiences.[11] Interactive Voice Response (IVR) systems are being used for mass messaging and sensitisation of communities in rural areas. Telemedicine has prevented a complete shutdown of healthcare, by facilitating connections and consultations with healthcare providers even through basic phones, against restrictions to physical mobility.[12] Emerging evidence around the use of robots and drones to deliver essential food and medical supplies to quarantined/affected areas, and disinfect health facilities and contaminated zones, as well as ensure availability of contraception and abortion products to women, are a testimony to the pace at which technology has been mobilised to respond to health needs during this pandemic.[13,14]

Bio-surveillance including diagnosis, contact tracing, and geotagging affected populations has been enabled real-time by governments’ health systems, to predict future trends, risks and response strategies. Innovations like AI-powered smart-helmets that pick up pedestrian temperatures[15] and use of smart-phone applications to monitor and track biometrics and movements of people, are examples of this.[16]

All of this portends a digitally infused public health system with the dual promise of achieving scale and granularity – diffusing into the many realms of health service and information delivery. Arguably, technology has an important role, yet it has been faced with many challenges in the past. The “digital divide” denies tech-access to significant proportions of the population; for instance, only one in five women have access to and use mobiles and the internet.[17] This divide is further amplified for adolescents. Moreover, while technology has been employed in response and relief measures, for enabling social networks, and giving access to institutionalised educational and health services, the same is not true for SRH information and support for young people. Thus, questions remain around adolescents’ dual disadvantage – poor access and enablement of technology for SRHR needs.

Invigorating the Tech agenda

While inequitable access is a key concern, it may not be long before public-private partnerships enter this space and enable pervasion of digital technologies. In Kenya, for instance, mobile companies like Safaricom have launched special phones and data packages to make smartphones accessible and affordable for women.[18] While these could be extended to adolescents as well, ASRH services are often not recognised as a priority, and would still need great effort and advocacy to actualise.

However, in small singular ways, ASRHR programmes have already been early adopters of technology because of its affordances for reach, engagement, anonymity and appeal amongst adolescents, and will likely further evoke its growing potential and role to respond to adolescent needs in myriad ways – tele-counselling on safe sex and contraception, interactive learning through AR/VR and gamification, multi-media content for behavioural and norms changes, tech-enabled and geo-tagged access to services and products, etc.

The catalyst to push this agenda would be donor funding and resources. While funding will prioritise epidemics preparedness, therapeutics, and delivery of essential services, there is need for strong evidence-based advocacy so that ASRHR does not get neglected.

Points of caution

Technology has zoomed into our intimate lives and spaces, providing connections with essential information and services, even throughout COVID-19 limitations.

The legitimacy of bio-surveillance technology to monitor the pandemic and mobility could threaten adolescents’ privacy, confidentiality, and agency, that are essential for them to be able to access information and services that is otherwise stigmatised.

We conjecture that as higher use of technology enables adolescents’ access to information and networks, it can at the same time also curtail such engagement due to self-censorship and broader surveillance.

In times of increasing state vigilance, ubiquitous technology may become a tool for surveillance, censorship, curbing dissent, and targeted discrimination and harm. Technology is not an agnostic domain, and interacts with social, cultural and political stratifications, intersecting with laws and policies that may be uniquely restrictive of adolescents’ SRHR.[19] Technology corporations and media platforms may be prone to comply with these norms and perpetuate “acceptability standards” that can put adolescents at further risk of censorship. The broader risks of cyber violence, bullying, profiling, are a considerable challenge with specific vulnerabilities for a younger age population.

These concerns may be a force to organise around – for young people, and for communities that work for the constituency, to protect adolescents’ SRHR. Understanding how best to support their agendas, upholding unique, intersectional and inclusionary voices for policies, programmes and donor attention will be important, to foreground concerns and prioritise privacy, safety and rights.

While enabling access to smartphones will be the biggest leveller for adolescent girls and boys, they will need to be empowered with digital literacy, including the ability to understand and engage with the diverse media that technology offers, their forms and functions, how data is stored and used, and ways to safeguard their own rights and privacy.

Organisations working on ASRHR would need to recognise the changed context and reconfigure their work accordingly, recognising considerations around privacy, beneficence and equity in their strategies, carefully considering the balance of reliance on technology and safeguarding against its harms. Equally important is to build capacities and resilience of physical infrastructure to provide services that technology cannot substitute for, and to prevent tech-hegemonies.

Zooming out

It is critical to create a vocabulary that recognises that ASRHR needs are essential, and to engage with and critically examine how technology can be evoked to support these, while promoting ethics, equity and rights. The pandemic has had multi-dimensional impacts that reinforce and remind us of the sobering effects from illness, health, agency, employment, education, societal growth and wellbeing, urging the ASRHR movements to move the discourse beyond “My Body, My Voice”, to “Our Bodies, Our Societies, Our Well-being”.

A young, healthy population that understands risk, imbibes principles of safety, and is skilled and empowered, can contribute to much needed reconstruction and reform as we look beyond COVID-19. For them, safety and freedom in making choices, and responsive programmes and services to address their SRH needs, are equally essential in building their capacities and autonomy, and in galvanising their trust and enthusiasm to work towards collective wellbeing and futures.