Developing Culturally Tailored mHealth Tools to Address Sexual and Reproductive Health Outcomes Among Black and Latina Women: A Systematic Review

Abstract

Background.

In addressing the sexual and reproductive health (SRH) disparities for Black and Latina women, there is a need for the development of innovative programs, framed using theoretical underpinnings that are culturally and contextually tailored so that they align with lived experiences. Mobile health (mHealth) interventions offer considerable potential as a means of providing effective SRH education and services. However, there has been a lack of research assessing culturally and contextually tailored mHealth SRH interventions for Black and Latina women.

Method.

A comprehensive literature search was undertaken using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Literature was reviewed to evaluate whether a culturally and contextually tailored approach was utilized in the development and implementation of mHealth interventions for Black and Latina women.

Results.

A total of 12 articles were included in our synthesis, which encompassed mobile phone–, telephone-, and computer-based mHealth interventions for Black and Latina women. Cultural and/or gender-specific tailoring was included in 10 studies. Reduction of risky sexual behaviors and increased contraception usage were reported in 92% (n = 11) of the studies. Interventions that incorporated tailored content and fostered interaction reported high rates of follow-up.

Conclusions.

Tailored mHealth interventions can be effective in promoting behavior change and improving SRH outcomes for Black and Latina women. However, there is a need for more research assessing user engagement and retention for Black and Latina women, and whether improvements in SRH outcomes are sustainable over the long term.

Black and Latina women in the United States are disproportionately affected by adverse sexual and reproductive health (SRH) outcomes compared with their White counterparts. Extensive research assessing the etiology of adverse SRH outcomes for Black and Latina women has suggested a complex interplay between individual, environmental, and contextual factors resulting in direct and indirect implications affecting their SRH (Hendrick & Canfield, 2017; Paradies et al., 2015). Both groups share higher risks of adverse SRH outcomes due to experiencing similar barriers as a result of their marginalized status; however, there are certain barriers that may be unique to each group. For example, although both Black and Latina women are more likely to face considerable challenges in navigating the health care system in general, Latina women who are immigrants may face certain distinct challenges such as language or access barriers related to their undocumented status (Foulkes et al., 2005; Rhodes et al., 2012). Factors that are specific to the lived experiences and realities of Black and Latina women necessitate the development of tailored SRH interventions that address ongoing disparities. To maximize impact, it is critical for SRH interventions to not only increase knowledge but also work to bolster skills and self-efficacy for young women while also targeting attitudes, intentions, and perceptions surrounding SRH (El-Bassel et al., 2009; Jenner et al., 2016). Although traditional SRH programs show effectiveness when tailored toward the needs of Black and Latina women, it has been difficult to implement such effective evidence-based interventions widely due to challenges related to recruitment and retention, financial constraints, ease of access, costs, and lack of personnel/staff (Hendrick & Canfield, 2017; James et al., 2016).

Advances in technology have resulted in a wave of novel digital and mobile health (mHealth) interventions, which have demonstrated considerable potential in reducing health disparities. mHealth modalities such as text messaging, phone counseling, internet, social media, and mobile apps have gained much traction among public health researchers in addressing public health outcomes among target communities (Anderson-Lewis et al., 2018). Digital health platforms offer several unique advantages for end users, such as enhanced anonymity, which enables users to feel more comfortable in revealing sensitive information pertaining to SRH and high-risk behaviors; this can facilitate the exploration of sensitive topics (Billings et al., 2015; Klein & Card, 2011). For low-literacy populations in particular, mHealth offers unique advantages through the use of audio and graphic components that can be easily disseminated, as well as interactive features that users can engage with (Klein & Card, 2011). Although mHealth encompasses numerous advantages, there has been a scarcity of mHealth interventions designed specifically for Black and Latina women in the United States. Notably, the development and sophistication of mobile technology for women has severely lagged in comparison with mobile technology and research that has been funded and developed for other populations (e.g., men who have sex with men; Liu et al., 2020; Nelson et al., 2020). There is a pressing need for more research generating rigorous evidence on mHealth technology designs that specifically target Black and Latina women’s SRH. The purpose of this systematic review is to summarize recent literature that has been published regarding the use of mHealth in addressing SRH disparities among Black and Latina women and to assess whether these programs were designed with content that was culturally and contextually tailored to the needs of these groups. We aim to provide researchers with relevant and current data that can be utilized in the development of mHealth programs that target Black and Latina women, with the goal of developing innovative solutions that alleviate SRH disparities.

METHOD

Search Strategy

Relevant articles were identified through a comprehensive literature search using PRIMSA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Peer-reviewed literature published between the years 2010 and 2020 was searched on PubMed and CINAHL databases. A search of gray literature was also conducted. Combinations of the following search terms were used to pull relevant articles: African American, Black, Latina, Hispanic, mHealth, mobile health, telehealth, technology, telemedicine, cell phone, mobile phone, sexual health, reproductive health, women’s health, risk reduction, HIV, STI, contraception, condom, prevention, and control. Filters were placed to limit search results to articles that were published within the past 10 years, limited to the female gender, and published in English. Reference lists of relevant systematic reviews were also screened to pull articles that did not populate from our initial search.

Eligibility Criteria

Included studies were written in English, peer reviewed, consisted of majority Black and Latina women in the study sample, and used mHealth to employ a primary prevention intervention focusing on SRH. For the purposes of this study, we defined SRH using the United Nations Population Fund (n.d.) definition as a guideline that encompasses family planning, STIs, HIV, contraception, and comprehensive sexuality education (L’engle et al., 2016). Abstracts, commentaries, editorials, and presentations were excluded. Studies that did not measure the effects of an mHealth intervention on SRH outcomes and that solely focused on the design, feasibility, and acceptability of mHealth programs were also excluded.

Study Selection

Our search yielded 428 articles that were uploaded for review on Rayyan QCRI (Qatar Computing Research Institute), a systematic review tool. Duplicates across databases were excluded, leaving a total of 426 articles. Titles and abstracts were independently screened by two reviewers, and disagreements were resolved by consensus. Our initial search found one systematic review by Blackstock et al. (2015), which focused on HIV mHealth interventions for adolescents and adult women; this was reviewed and screened for relevant articles. After the initial screening of all articles, 34 articles were retained, and their full texts were reviewed to judge whether they should be included for further synthesis. Following full text review, 19 articles were excluded for the following reasons: wrong population (n = 9), wrong outcome (n = 9), and wrong publication type (n = 2). The remaining articles were then graded on the quality of evidence using the Johns Hopkins Nursing Evidence Level and Quality Guide (Dang & Dearholt, 2017). In grading quality, the authors assessed study methodology, results, whether conclusions were consistent, along with whether comprehensive literature reviews were conducted that included thorough reference to the scientific evidence presented (Dang & Dearholt, 2017; Guillaume et al., 2020). Afterward, the articles were appraised using the Joanna Briggs Institute’s critical appraisal tool (Joanna Briggs Institute, 2017). During the appraisal process, one study was excluded due to yielding low quality of evidence, resulting in a total of 12 articles for final synthesis.

RESULTS

Population

The majority of studies (n = 10) targeted adolescents and young adults ranging from ages 13 to 29 years (Card et al., 2011; Castaño et al., 2012; Chernick et al., 2017; Danielson et al., 2013; DiClemente et al., 2014; González Gladstein, 2018; Jones et al., 2013; Jones & Hoover, 2018; Klein & Card, 2011; Manlove et al., 2020). One study targeted a broader age range of 18 to 50 years (Billings et al., 2015), and one study targeted all individuals older than 18 years (El-Bassel et al., 2014). Both Black and Latina women were included in seven studies (Castaño et al., 2012; Chernick et al., 2017; El-Bassel et al., 2014; González Gladstein, 2018; Jones et al., 2013; Jones & Hoover, 2018; Manlove et al., 2020). Five studies exclusively targeted Black women (Billings et al., 2015; Card et al., 2011; Danielson et al., 2013; DiClemente et al., 2014; Wingood et al., 2011). There were no studies that exclusively targeted Latina women.

Study Quality

The majority of studies (n = 9) were randomized controlled trials (RCTs). There was one secondary analysis from an RCT that was included in our analysis, and two studies were pretest–posttest designs. All included studies utilized quantitative methodology (Table 1).

TABLE 1.

Characteristics of Included Studies Assessing Sexual and Reproductive Mobile Health Interventions Among Black and/or Latina Women

Author, year	Study population	Study design	Intervention	Sexual and reproductive health focus	Inclusion of tailored content	Inclusion of interactive content	Results	Attrition
Computer-based interventions
Billings et al. (2015)	Black women 18 to 50 years defined as high risk for HIV.	RCT, N = 83	Intervention: Safe Sistah computer web-based program participants had 1 month to view program. Control: Participants had access to Safe Sistah program on study completion.	HIV prevention through focusing on condom negotiation.	Yes; content included HIV prevention skills adapted to challenges Black women face throughout their daily lives. Audio narration was conducted using the voice of a Black women with photos of Black women being included. Risk reduction plans were individually tailored based on the user’s risk profile. Gender-specific prevention skills included with content focused on gender empowerment and positive racial identity.	Yes; video clips, audio narration, interactive exercises, and quizzes incorporated in the intervention.	Condom-protected sex acts were higher among intervention participants compared with controls across the entire 1-month study period (p = .027). This finding also applied to condom use after drinking (p = .007). Women in the experimental group significantly increased their sexual communication across the entire study period (p = .033).	87% of participants in intervention completed 4-month follow-up; 89% in control completed 4-month follow-up. Women with less income were more likely to be lost to follow-up (p = .013).
Card et al. (2011)	Black women aged 18 to 29 years who were unmarried, noncohabiting, and reported unprotected vaginal sex in the past 30 days.	RCT, N = 135	Intervention: SAHARA web-based program based on the evidence-based face-to-face SISTA intervention. SAHARA was supplemented by a 20-minute in-person debriefing session with a Black female health educator. Control: General in-person health education control condition consisting of 1-hour group session run by a Black female facilitator designed to represent routine care that clients typically receive.	HIV prevention through consistent condom use during vaginal sex.	Yes; content included cultural and gender relevant material to promote pride and enhance self-worth in being a Black woman. Cultural and gender barriers and facilitators to condom use were incorporated into the program.	Yes; video clips that featured group discussions and interactive modules were included that provided learning experiences via games, quizzes, and simulated role-play.	Participants in intervention had higher STI knowledge scores and higher condom use self-efficacy scores (p < .012). Intervention participants had higher condom protected sex acts (p < .03) and were more likely to use condoms consistently for sex (p < .039).	Not reported.
El-Bassel et al. (2014)	Black (68%) and Latina (15%) women who identified as drug offenders over the age 18 years.	RCT, N = 306	Intervention: Traditional WORTH arm consisted of four HIV prevention sessions with a group facilitator leading face-to-face activities once a week between 90 and 120 minutes. Multimedia WORTH arm consisted of a computer program intervention with weekly group meetings. The multimedia intervention was delivered through a combination of self-paced activities and multimedia group–based activities where a facilitator guides group members. Control: Wellness promotion arm was delivered in a group setting with trained facilitators discussing general health promotion content.	HIV/STI risk reduction intervention using a group-based traditional intervention compared with a multimedia prevention intervention.	Yes; gender-specific HIV/STI prevention content was included, along with gender-specific psychoeducational and skills building content.	Yes; self-paced interactive activities were included (e.g., computer games, video enhancements, interactive visual tools) along with risk maps and social support features. Identification and emotional engagement were enhanced through four fictional role models used in video vignettes.	There was a 28% reduction in the number of unprotected sex acts for participants in both intervention groups when compared with participants in the wellness promotion arm. Both intervention groups had significant effects in lowering the number of unprotected sex acts, increasing the proportion of protected sex acts, and increasing consistent condom use. The incidence for any STI at 12-month follow-up did not significantly differ between the two WORTH conditions and the wellness promotion condition.	The retention rates at each follow-up, which were 87% or higher for all three follow-up assessments, did not significantly differ by condition. Attrition analyses identified that completers on average were older (42 vs. 39 years) and less likely to report homelessness (8% vs. 18%)
Klein and card (2011)	Black women aged 14 to 18 years.	RCT, N = 178	Intervention: Multimedia SiHLE-based off traditional face-to-face SiHLE that was developed into a 2-hour computer delivered individual-level intervention. Control: General health education session lasting 65 minutes.	Social skills intervention targeting reducing HIV risk behaviors.	Yes; an Afro-centric focus was incorporated throughout the framework and as a core element. Ethnic and gender pride were enhanced while emphasizing HIV risk factors that are prevalent among Black teenage females.	Yes; interactive components included games, quizzes, group discussions, stimulated role plays, and take home exercises.	Participants in the intervention had a significantly higher percentage of condom use from baseline to 3-month follow-up (p = .05) along with higher HIV and STI knowledge levels (p < .001). Condom self-efficacy increased among nonsexually active participants (p = .02). No changes were found in sexual communication self-efficacy among both intervention or control groups.	91.2% of participants in the intervention and 90.8% of participants in control arm completed 3-month follow up.
Phone intervention
Castaño et al. (2012)	Women aged 13 to 25 years with the majority of participants being either Black (39%) or Latina (29%)	RCT N = 968	Intervention: Daily unidirectional text messaging providing reproductive health text message content coupled with routine care. Routine care following health center protocols that included contraceptive counseling by staff and the provision handouts detailing contraception information, plus daily texting for 6 months. Control: Routine care following health center protocols that included contraceptive counseling by staff and the provision of handouts detailing contraception information	Oral contraception pill (OCP) continuation.	Tailored content was not included.	Of the 180 messages sent, 12 messages were two-way messages asking for participant feedback.	64% of participants in the intervention group were OCP users compared with the control group (p = .005) at 6-month follow-up. Participants in intervention group were more likely to continue with OCP at 6 months compared with control participants.	Follow-up information was obtained from 71% of participants at 6 months. Those lost to follow-up were younger, had completed fewer years of school, were less likely to identify as Hispanic, more likely to have been pregnant or given birth, and less likely to be current users of OCPs (all p < .03).
Chernick et al (2017)	Predominately Hispanic (83.7%) and Black (14.3%) adolescent females aged 14 to 19 years.	RCT, N = 100	Intervention: Unidirectional text messages for 3 months containing education coupled with action components focused on contraception initiation. Control: Standard referral that included wallet card providing information on a family planning clinic, along with a standardized monologue given by an ED physician on reproductive care.	Effective contraception initiation.	Yes; text message content was developed based on prior work from the first author who identified barriers and facilitators toward contraceptives; however, the authors failed to state whether the content was tailored toward culture and/or gender.	Interactive components were not included.	The control group had a higher rate of contraception initiation (22.4%) compared with the intervention group (12.0%); 32% of participants in the intervention attended family planning compared with 30.6% in the control arm.	More patients in the intervention arm (16%) than in control arm (8.2%) were lost to follow-up.
DiClemente et al. (2014)	Black adolescents and young adults aged 14 to 20 years.	RCT, N = 701, 36 months	Intervention: In-person CDC Horizons program in addition to supplemental treatment consisting of tailored telephone counseling 10-minute sessions every 8 weeks over 36 months. Control: Horizons program with telephone counseling placebo intervention consisting of general health promotion that was time and dose equivalent to the intervention.	HIV and STI prevention.	Yes; extensive qualitative research was conducted with adolescents prior to study implementation to assess gender and cultural appropriateness and relevancy of the intervention. Risk appraisals were conducted with participants and health educators tailored telephone counseling strategies to participant risk factors that were identified	Group discussions, question-and-answer sessions, culturally and gender appropriate HIV/STI prevention videos were included	At 36-month follow-up fewer participants in the intervention group had incident chlamydial and gonococcal infections. Participants in the intervention group reported higher rates of condom use (p = .02) and fewer episodes of sex acts under the influence of alcohol or drugs (p < .001).	Higher retention rates were seen in the intervention group at 6 months (81% vs. 75%), 12 months (73% vs. 71%), and 36 months (62% vs. 60%).
González Gladstein (2018)	Black and Latina women aged 18 to 25 years.	RCT, N = 114	Intervention: GURHL Code online smartphone application that provided sexual and reproductive health education coupled with linkage to care services. Control: An alternate website consisting of a single page listing of clinic information and trusted sexual and reproductive health website resources.	General sexual and reproductive health (HIV, STI, condom use, hormonal birth control).	Yes; a community advisory committee was consulted and focus groups were conducted to finalize the content and design of the GURHL Code app to ensure cultural and gender relevancy for Black and Latina women.	Interactive components included audio stories, quizzes, and video content.	At 3-month follow-up, the intervention group had increases in knowledge scores regarding condom use, HIV, and STI rates among youth more than the control group although this increase was modest.	92% of participants in the intervention arm completed 3-month follow up assessment compared with 90.6% in the control arm with no significance found between treatment conditions.
Jones et al. (2013)	Black, Latina, and Caribbean women aged 18 to 29 years.	RCT, N = 238	Intervention: Love, Sex, Choices a 12-episode soap-opera web-based video series shown weekly on video phones over the span of 12 weeks. The video series incorporated sexual health promotion messages. Control: Text message control arm received 12 HIV prevention text messages with CDC-backed content.	Reduction of HIV risk through reducing unprotected vaginal and unprotected anal sex acts.	Yes; the video series was tailored to Black and Latina women based on formative research assessing sex scripts among Black and Latina women. Characters in the video series were developed based on focus groups with Black and Latina women to ensure cultural and gender relevancy.	After each video, weekly emails were sent out with questions to evaluate the content in the video that was watched.	Unprotected vaginal and anal sex acts with a high-risk partner were significantly lower postintervention for both the intervention and control arms (p < .001) at 6-month follow-up. Although there was an 18% greater reduction in unprotected vaginal and anal sex acts among the video intervention, the difference was not statistically significant.	Only two of the 117 participants in the video group missed an episode; nearly all watched each episode fully or more than once.
Jones and Hoover (2018)	Black, Latina, and Caribbean women aged 18 to 29 years.	Secondary analysis of RCT, N = 238	Intervention: Love, Sex, Choices a 12-episode soap-opera web-based video series shown weekly on video phones. The video series incorporated sexual health promotion messages. Control: Text message control receiving 12 HIV prevention text messages with CDC-backed content.	This secondary analysis assessed the impact of the original Love, Sex, Choices video series intervention developed by Jones et al. (2013) on sex scripts.	Yes; video series was tailored to Black and Latina women based on formative research assessing sex scripts among Black and Latina women. Characters in the video series were developed based on focus groups with Black and Latina women to ensure cultural and gender relevancy.	After each video, weekly emails were sent out with questions to evaluate the content in the video that was watched.	Both the experimental and control group had statistically significant declines in Sex Script Video Response (SSVR) scores at 6-month follow-up. The decline in SSVR scores was greater among intervention group versus control (p < .001).	Only two of the 117 video group missed an episode; nearly all watched each episode fully or more than once.
Manlove et al. (2020)	Black and Latina women aged 18 to 20 y	RCT, N = 1,304	Intervention: Pulse sexual and reproductive health app designed to address sexual health and behavioral determinants of Black and Latina young women over the span of 6-weeks. Control: A general health promotion app focused on healthy eating, exercising, sleep and general health.	This study focused on teen pregnancy prevention primarily through increasing condom use along with hormonal contraception use.	Yes; during app development, various focus groups were held with Black and Latina youth advisors to obtain feedback on content and design. Pulse was updated with new content, inclusive language, and new graphic designs to appeal to target population. App content was also informed by a review of studies that analyzed knowledge, attitudes, gaps, and contraceptive behaviors among Black and Latina women.	Pulse contained six interactive sections on various sexual and reproductive health topics (birth control, STIs, pregnancy, healthy relationships, consent) that contained core activities and videos while also linking participants to sexual and reproductive health services/clinics through the app.	Participants in the intervention arm were less likely to report having sex without a form of contraception (p = .000) and had higher contraception knowledge scores (p = .027) compared with those in the control group.	Minimal attrition was reported among both arms; 85% of participants in the intervention group and 87% of participants in the control group completed posttest survey.
Danielson et al. (2013)	Black female adolescents 13 to 18 years.	Pilot trial, N = 41	Intervention: SiHLE Web a web-based adaptation of the traditional face-to-face SiHLE intervention. SiHLE Web consisted of 1-hour sessions. Control: N/A	HIV and STI risk reduction through increasing consistent condom use and decreasing unprotected sex, number of new sexual partners, and number of new diagnosed STI infections.	Yes; SiHLE Web was based off of the original SiHLE program, which was culturally tailored targeting African American adolescent girls.	SiHLE Web consisted of four 1-hour sessions that simulated the experience of live group participation using an interactive, video-based design. Character development through video content was incorporated as well. SiHLE Web users had the opportunity to complete interactive activities and receive real-time feedback on their responses from their video peers, health educator, and near peer.	Among completers of the full website, condom use self-efficacy significantly increased (p = .03). Knowledge significantly improved for STD education and condom demonstration (p < .01). Knowledge did not significantly improve for ethnic and gender pride, communication and assertiveness, healthy relationships and self-care.	63.4% of all girls recruited into the study completed the intervention, taking an average of 4.5 visits to complete the content. Among those logging into the site at least once, the average girl completed over three quarters (3.72 out of 4) of the intervention.

Note. RCT = randomized control trial; STI = sexually transmitted infection; SAHARA = Sistas Accessing Health Resource; WORTH = Women on the Road to Health; SiHLE = Sistas Information, Healing, Living, and Empowerment; STD = sexually transmitted disease; ED = emergency department; N/A = not applicable; CDC = Centers for Disease Control and Prevention.

Outcome Measures

Increased condom use was the most common primary outcome measure reported among studies (Billings et al., 2015; Card et al., 2011; Danielson et al., 2013; DiClemente et al., 2014; El-Bassel et al., 2014; Jones et al., 2013; Jones & Hoover, 2018; Klein & Card, 2011). Two studies reported oral contraception initiation and adherence as their primary outcome measures (Castaño et al., 2012; Chernick et al., 2017). A study conducted by Manlove et al. (2020) focused on the initiation of various hormonal contraceptive methods (e.g., oral contraceptive pills, progestin injections, intrauterine devices, transdermal patch) along with increasing birth control knowledge as the primary outcomes (Manlove et al., 2020). González Gladstein (2018) reported a primary outcome measure of changing SRH knowledge levels among study participants. Biological outcomes were measured in two studies, with one study measuring laboratory-confirmed STIs postintervention (e.g., chlamydia and gonococcal infections; DiClemente et al., 2014), and the other measuring laboratory-confirmed STIs along with HIV (El-Bassel et al., 2014). Secondary outcome measures widely varied among studies and included condom use after alcohol and drug consumption, sexual communication, self-esteem, healthy relationships, and increasing knowledge surrounding HIV and STIs.

Computer-Based Interventions

Five studies employed web-based computer interventions focusing primarily on HIV and STI risk reduction among Black women (Billings et al., 2015; Card et al., 2011; Danielson et al., 2013; El-Bassel et al., 2014; Klein & Card, 2011). All five studies were adaptations of original face-to-face interventions, which were used to guide the development of the computer-based multimedia interventions (Card et al., 2011; Danielson et al., 2013; El-Bassel et al., 2014; Klein & Card, 2011). Cultural and gender-specific tailoring were incorporated throughout all computer-based interventions, with a particular emphasis on ensuring that core elements possessed an Afrocentric focus. More specifically, culturally and gender-specific tailored components that were included enhanced ethnic and gender pride, discussed the challenges and joys of being a Black woman, discussed Black women’s unique risk factors, and incorporated skills adapted to the distinctive challenges that Black women face in their daily lives (Billings et al., 2015; Card et al., 2011; El-Bassel et al., 2014; Klein & Card, 2011; Klein et al., 2013). Interactive features (e.g., videos, quizzes, games, interactive exercises and modules, audio presentations, group discussions, social support) were integrated throughout all five computer interventions. The Safe Sistah HIV prevention web-based intervention developed by Billings et al. (2015) was distinct from the other computer-based interventions in that it included individual tailoring to participants based on their specific sexual risk profile, along with a personalized risk reduction plan (Billings et al., 2015).

Across all studies, participants reported significant increases in condom use and a reduction in unprotected sexual acts (Billings et al., 2015; Card et al., 2011; Danielson et al., 2013; El-Bassel et al., 2014; Klein & Card, 2011). Knowledge surrounding HIV, STIs, and risk-reduction behavior increased among participants in three studies (Billings et al., 2015; Card et al., 2011; Danielson et al., 2013). However, Billings et al. (2015) reported that these knowledge levels were not sustained at follow-up. Among studies that measured self-esteem and sexual communication, only one study reported significant findings, despite all studies incorporating tailored content that promoted cultural and gender pride (Billings et al., 2015).

Mobile Phone– and Telephone-Based Interventions

Seven studies employed mobile phone– or telephone-based interventions. Interventions included text messaging (Castaño et al., 2012; Chernick et al., 2017), mobile phone apps (González Gladstein, 2018; Manlove et al., 2020), videophone devices (Jones et al., 2013; Jones & Hoover, 2018), and a telephone-based counseling intervention (DiClemente et al., 2014). The majority (n = 5) of these interventions incorporated content that was tailored toward culture and/or gender (DiClemente et al., 2014; González Gladstein, 2018; Jones et al., 2013; Jones & Hoover, 2018; Manlove et al., 2020). DiClemente et al. (2014) included tailoring toward individual participant risk factors that were identified from a baseline risk assessment in addition to cultural and gender tailoring. Among the mobile phone interventions that included tailored content, participants experienced increases in knowledge regarding contraception, HIV, and/or STIs; participants were more likely to use contraception; and participants were less likely to participate in risky sexual behavior (DiClemente et al., 2014; González Gladstein, 2018; Jones et al., 2013; Jones & Hoover, 2018; Manlove et al., 2020).

Two studies utilizing mobile phones to increase contraception uptake did not include cultural or gender-specific tailored content (Castaño et al., 2012; Chernick et al., 2017). Chernick et al. (2017) implemented a one-way text-messaging intervention to increase oral contraceptive pill (OCP) initiation primarily among Latina youth and reported lower rates of contraception uptake in the text message intervention arm compared to the control arm (Chernick et al., 2017). Castaño et al. (2012) employed a daily text-messaging intervention that primarily consisted of one-way text messages to increase OCP uptake among Latina and Black youth. The authors reported higher OCP continuation rates among participants in the text-message intervention arm compared with the control.

Attrition and Loss to Follow-Up

Overall retention was high among the majority of studies, with the majority of studies reporting retention rates of over 80% (n = 9). Among included studies that utilized mobile phone– and telephone-based mHealth interventions, Castaño et al. (2012) reported the highest rates of loss to follow-up; the researchers were unable to reach 29% of participants at 6-month follow-up. In an attrition analysis, it was found that participants lost to follow-up had higher rates of service interruptions, were younger, had completed fewer years of school, were less likely to identify as Hispanic, less likely to be active users of OCPs, and were more likely to have been pregnant and given birth (Castaño et al., 2012). Interestingly, in the one-way text message intervention employed by Chernick et al. (2017), higher rates of attrition were found in the intervention group in comparison with the control group. For studies that used computer-based mHealth interventions, the SiHLEWeb (Sistas, Informing, Healing, Living, and Empowering) intervention developed by Danielson et al. (2013) had the highest rates of attrition, with 36.6% of participants not completing the web series. The most commonly cited reasons for not completing the program among study participants included being too busy, not finding the site helpful, lacking internet access, and forgetting how to access the site (Danielson et al., 2013).

DISCUSSION

This systematic review identified and summarized literature published on the use of mHealth in addressing SRH outcomes among Black and Latina women. Among included studies, mobile phones were the most common platform used to employ mHealth interventions. This is important to highlight given that evidence has suggested an association with mobile phone access among women in low-resource settings being associated with improved SRH outcomes (Lefevre et al., 2020). Research has demonstrated that mobile phone access increases women’s decision making, increases access to health resources, positively influences gender relations, and increases health communication (Lefevre et al., 2020). Across the included studies, mHealth interventions that incorporated cultural and contextual tailoring had demonstrated efficacy in improving SRH outcomes, particularly increasing condom use and decreasing risky sexual behavior. These findings are consistent with literature demonstrating that SRH interventions have increased effectiveness in reducing risky behavior when content is tailored and reflects the true life circumstances and experiences of Black and Latina women (Chandler, Hernandez, et al., 2020; Evans et al., 2020; Gilbert & Goddard, 2007; Villarruel et al., 2005).

One particular challenge that has been prevalent in the application of mHealth among Black and Latina women has been retaining users and promoting user engagement over longer timeframes. For Black and Latina women, this challenge has been especially noteworthy due to their overall lack of inclusion in mHealth research. While this lack of inclusion can be attributed to a myriad of personal, structural, and contextual factors, it is important to also note the lack of adequate recruitment efforts on part of study investigators (e.g., research not targeting minorities, lack of minority researchers, mistrust of researchers; James et al., 2016). Consequently, there are significant gaps in knowledge in not only recruiting Black and Latina women in mHealth interventions but also retaining them in mHealth interventions. Among included studies, those with lower attrition rates incorporated gender and culturally tailored content in addition to interactive multimedia features. The video intervention developed by Jones et al. (2013) was exemplary in demonstrating how interactive and tailored content could increase engagement and reduce attrition. It was found that only two out of 117 participants missed an episode and that nearly all the participants in the intervention group watched each episode fully or more than once (Jones et al., 2013). Participants in this intervention showed high levels of engagement that were largely attributed to the relatability of the content and Black women’s ability to see themselves within the characters and their trajectories (Jones et al., 2013). In contrast, the text message intervention developed by Chernick et al. (2017), which did not include cultural or gender tailored content, reported higher rates of attrition in the intervention arm compared to the control arm; coupled with lower contraception initiation rates in the intervention arm (Chernick et al., 2017).

Two studies in our review included content that was individually tailored based on each end user’s sexual risk profile and provided personalized risk-reduction plans (Billings et al., 2015; DiClemente et al., 2014). Both interventions were highly effective in reducing risky behavior. In addition, Billings et al. (2015) reported significant increases in communication and self-esteem among study participants. This was a key finding given that among studies that measured increased self-esteem and healthy communication as a secondary outcome; Billings et al. (2015) was the only study that reported statistically significant findings. It is possible that the inclusion of personalized risk reduction plans and individual tailoring may be beneficial in further reducing risky sexual behavior through improving women’s self-esteem, providing them with a sense of empowerment, and increasing their comfort in negotiating safe sex practices.

Innovative content delivery that promotes cultural and contextual relevancy, while incorporating creative interface designs that attract the attention of Black and Latina women, is imperative for fostering interaction and engagement with mHealth interventions (Brayboy et al., 2017; Chandler, Guillaume, et al., 2020; Jones et al., 2013). It is critical for researchers and developers to bear in mind that user engagement with mHealth technology occurs on a continuum encompassing a combination of captivating and rich interfaces, feedback, interactivity, and relatable and tailored content that invokes interest among users (Chandler, Guillaume, et al., 2020; O’Brien & Toms, 2008). In designing mHealth programs for Black and Latina women, it is critical to include their perspectives and opinions concerning content that speaks to their needs and experiences and to design interfaces that capture their attention, throughout the program development phase. When interventions are developed with these elements in mind, they can offer promising solutions in providing SRH content to those who otherwise would not have access to such information. As a result, missed opportunities in providing SRH education to Black and Latina women can be avoided. Through applying what is understood about the origins of health disparities and ensuring that cultural and contextual tailoring is incorporated in the design of SRH programs, researchers can develop mHealth interventions that foster relatability, thereby increasing the impact of mHealth in addressing SRH disparities (Chandler, Guillaume, et al., 2020).

Implications for Research and Practice

mHealth interventions that are deemed feasible and acceptable among Black and Latina women can be used to guide public health policies that can reduce SRH disparities among this priority community. Given the dearth of research on user engagement with mHealth among Black and Latina women, future studies should assess barriers to user engagement among this population, along with obtaining inputs regarding the components and features they desire to see incorporated within mHealth interventions to reduce attrition rates (Chandler, Hernandez, et al., 2020). By collaborating with communities and potential end users, research teams can establish trust with these populations, thus reassuring women that they are receiving a user-centered intervention that contains trusted information around sensitive SRH topics (Chandler, Hernandez, et al., 2020). This is of significant importance given how Black and Latina women have been largely underrepresented in mHealth research interventions.

The use of mHealth as a platform to provide SRH information to at-risk communities can play a significant role in addressing the upstream (e.g., socioeconomic status) and downstream (e.g., risk behavior change) determinants that effect SRH outcomes among this priority population (Barkman & Weinehall, 2017; Chandler, Guillaume, et al., 2020). The use of mHealth as a platform to provide SRH information to at-risk communities can play a significant role in addressing the upstream (e.g., socioeconomic status) and downstream (e.g., risk behavior change) determinants that affect SRH outcomes among this priority population (Barkman & Weinehall, 2017; Chandler, Guillaume, et al., 2020).

Although we conducted a comprehensive literature search focusing on mHealth interventions for both Black and Latina women, our search populated very few studies focusing on interventions developed for Latina women. While Black and Latina women share similar personal, structural, and contextual barriers that effect their SRH outcomes, there is a need for interventions that acknowledge and address the unique barriers that Latina women face as well. Dynamic and evolving digital interventions should also be considered in future research, as such interventions can be sensitive to trends linking certain SRH health outcomes among Black and Latina women (Chandler, Guillaume, et al., 2020). With the popularity of social media use among adolescents and young adults, future studies should assess how social media can be used as a platform to provide accurate SRH information and linkage to care services.

Limitations

Given the literature search strategy, it is possible that relevant articles were not pulled from our search and therefore were excluded from our analysis. Given the dearth of literature on this topic, there is a need for more rigorous research to draw conclusions on how mHealth can be used to bridge SRH gaps among Black and Latina women.

CONCLUSION

Our review demonstrates that when mHealth interventions are appropriately developed and tailored to meet the needs of target populations, they can be effective in promoting behavior change and improving SRH outcomes. However, more studies are needed to evaluate whether these improved SRH outcomes as a result of mHealth interventions are sustainable over the long term. Interventions that not only increase SRH knowledge but also promote behavior change through interactive content that is tailored to meet the unique needs and experiences of Black and Latina women will be imperative for addressing the current health disparities that exist among this population. When developed with the target community in mind, mHealth can overcome substantial barriers and offer significant potential in improving SRH among Black and Latina women who otherwise may not have access to SRH content.