Study Aim, Study Design, Population and Setting. The aim of the study was to determine if the Nthabi Health Promotion Application improves participant’s knowledge after using Nthabi compared with before using the App. We enrolled 172 young women from the two rural districts of Leribe and Berea in the mountainous, low-middle income country of Lesotho in southern Africa.
Recruitment. The research team recruited participants by posted messages on social media (e.g., WhatsApp and Facebook) that described the study and asked potential participants to contact the research team to discuss enrolling in the study., A local non-governmental organization called Help Lesotho that offers mentorship programs to adolescent girls and young women in the Leribe district, reached out to the research team after seeing the social media posting and offered to disseminate the recruitment announcement to their clients.
Second, the research team approached young women while they were waiting for consultation in the Adolescent Health Corners [e.g., clinics], the HIV, and Mother and Child Health ambulatory clinical departments at the Berea and Leribe government district hospitals. Third, students were approached at the Leribe Vocational School and the Limkokwing University of Technology to identify those interested in participating.
Eligibility and Enrollment. The inclusion criteria were: (1) Basotho women aged 18–28 years who were from the districts of Leribe or Berea and who accessed health services in these two districts, (2) self-reported ability to read and understand spoken English, (3) have access to an Android smartphone, (4) able to access internet and Wi-Fi at least once at the end of the study.
Informed Consent, Enrollment. Once eligibility criteria were established, the research team explained the purpose of the study, potential risks and benefits, reimbursement for travel costs, and the right to withdraw from the study at any time. After addressing any questions, participants were asked to sign an informed consent.
The research team then assisted the participants to download the App on their mobile phones. Participants who were unable to download the App were loaned a Lenovo© Android 11 OS platform tablet to use for six weeks. Participants created a unique username and password and were shown how to log on to their mobile phone or tablet. Participants then began interactions with Nthabi and were encouraged to use the app at least once daily at their convenience for six weeks.
Baseline Data Collection. Socio-demographic information was collected (age, marital status, educational level, employment status, recruitment site, and district).
Nthabi Intervention Description. We previously described [24] how we adapted an ECA used in the United States ("Gabby") to create an agent ("Nthabi") whose physical characteristics and language, and the clinical contents it presents, are appropriate for Lesotho. 24 Adaptations explored physical and cultural alternatives including the character’s sex, age, occupation, name, physical appearance (hairstyle, clothing), language and speech patterns, and personality believed to resonate with young Basotho women.
The final Nthabi’s appearance and persona represent a Mosotho professional nurse midwife wearing a Lesotho nurse’s uniform. Her hairstyle (braids), complexion (medium, similar to the local population), facial expressions (calm and gentle), and mannerisms (a humble professional with a sense of humour) are relatable to young women in Lesotho (Fig. 1).
Nthabi’s language is English, as the English literacy rate among young women in Lesotho is above 90%, and English is spoken in health settings.
To establish the clinical topics to be included in the system, Lesotho Ministry of Health key informants recommended five sexual reproductive health topics for young women (family planning, HIV, tuberculosis (TB), healthy eating and use of folic acid). The research team then used the Lesotho National Clinical Guidelines to create evidence-based dialogue for use in each of the five content areas discussed in Nthabi interactions.16
Participants chose from a list of the five health topics offered by Nthabi. Using conversational dialogue, Nthabi describes why the topic is important and offers suggestions about how to take action on it. Participants engage by selecting a response from a multiple-choice menu updated at each turn of dialogue. For family planning, folic acid and healthy eating, Nthabi requests that participants take a knowledge pre-test before providing health education, and when they completed the topic, the participants were asked to take a post-test. There were no pre-post interaction questions for HIV and TB as these topics were designed to test the impact of motivational dialogue on health behaviors. These data will be presented separately.
Finally, technical adaptations were required to deploy Nthabi on smartphone screens rather than computer screens as done in the Gabby prototype. We constructed the app to be fully downloadable to users' mobile phones so that its availability would not require Wi-Fi access. Usage and information about the health content discussed would be downloaded to the server when the user is in a Wi-Fi environment. Nthabi was made available on Google Play store for download on mobile phones or tablets.
Data Collection. When the participant is in a Wi-Fi environment, the data collected through conversations with Nthabi is automatically downloaded to a secure server collecting the following metrics: number of logins, number of interactions with the system and the number of topics completed and pre and post-test results. Participants were invited to return to the recruitment site to access the internet at the completion of the study to facilitate downloading interaction data to the server, and to return the loaned tablets.
Data Storage and Analysis. Data from the server were extracted, captured on an Excel spreadsheet, and stored on a password-protected computer. Data were analysed using SAS statistical software (v9.4). The number of correct pre- and post-test responses were compared using generalized linear models that directly estimated the proportions (and percentages) of correct responses. For individual items, the models accounted for the pre-and post-test responses being paired for each participant. Models that compared paired responses across all multiple items also accounted for the clustering of multiple responses within individual participants. P-values of < 0.05 were considered statistically significant.
Participant Incentives. All participants received 50 Maloti (approximately $5) to cover the cost of using phone data. Participants using tablets received an additional 50 Maloti to cover their travel back to the recruitment sites to return the devices.
Ethical Clearance. The study was conducted according to the Consolidated Standards of Reporting Trials (CONSORT). Ethical clearance was obtained from the Sefako Makgatho University of Health Sciences Ethics Review Committee (SMUREC/H/343/2021: PG), Boston University Research Institutional Review Board (IRB Number: H-40268), the Lesotho Ministry of Health Research Ethics Committee (ID 145–2021), and permission was obtained from the study recruitment sites.