Assessing Needs for Comprehensive Zika Avoidance Messaging for At-Risk Women in the U.S.-Mexico Border Region

Abstract

BACKGROUND: Zika virus poses a severe health threat to pregnant women, yet few public health responses thus far have addressed barriers to behavior change to reduce mosquito-borne and/or sexual spread. Zika’s effects are most severe for pregnant women, who are unlikely to be using a barrier method during pregnancy. Pregnant women are commonly aware that Zika is transmitted by mosquitos, but not that sexual transmission is a secondary route. The potential role of intimate partner violence in preventing the sexual spread of Zika (i.e., via condom use negotiation) is not well understood and has not been addressed in prevention education. Women in the U.S.-Mexico border region of Arizona represent one key population that may be at risk of a future Zika epidemic. Mobile health (mHealth) outreach is ideal to engage this population as it provides participants with flexibility and privacy commensurate with sensitivity to discussing topics such as sexual activity or birth defects. OBJECTIVES: This dissertation is composed from three studies that address the following aims: 1) to assess existing mHealth interventions to reduce or mitigate IPV in any form, including sexual assault and coercion, physical violence, and emotional control or abuse, any of which may influence successful engagement in Zika prevention behaviors; 2) to estimate the population-level dissemination of public health information throughout Arizona on the sexual transmissibility of Zika to women who were pregnant or intending to become pregnant during the 2016-2017 epidemic; 3) to identify factors that influence mosquito bite risk and subjective condom use norms among Spanish-speaking Mexican-origin women in a Zika risk area, as well as preferences for mobile message delivery. METHODS: A systematic literature search was conducted for Aim 1 to synthesize existing efforts to address intimate partner violence victimization using mobile or other web-based programs. Aim 2 included a quantitative analysis of data collected in Arizona to measure the dissemination of sexual transmission messaging and to explore patterns of seeking health information that could explain why some women were aware of sexual transmission of Zika. Aim 3 pilot tested a web-based platform (WhatsApp) to collect online focus group data with Spanish-speaking, Mexican-origin women in the U.S.-Mexico border region of Arizona, both to explore its logistical feasibility for broader use and to establish initial qualitative evidence for health messaging needs that will improve Zika sexual transmission knowledge and prevention behaviors within the same population. RESULTS: Regarding Aim 1, mHealth tools for intimate partner violence prevention were found to be especially acceptable in healthcare settings, on mobile phone platforms, or when connecting victims to healthcare. Despite enthusiasm in pilot projects, evidence for efficacy compared to conventional IPV prevention approaches is limited. A major strength of mHealth intimate partner violence prevention programming is the ability to tailor interventions to individual recipient needs without extensive human resource expenditure by providers. The analysis performed for Aim 2 found that Arizona women who were pregnant or intending to become pregnant had no better knowledge of the sexual transmissibility of Zika than other women of childbearing age (AOR=1.02 [0.62,1.67]), nor compared to the general population of respondents (AOR=0.84 [0.62,1.13]). Only about one-third of all respondents reported knowledge of sexual transmission. Reliance on high- versus low-dependability information sources, whether in-person or online, did not predict extent of Zika knowledge. Findings for Aim 3 suggest that WhatsApp is a secure, low cost, logistically feasible means of producing rich qualitative data from a population that is often reticent to engage in traditional research; participants strongly preferred to receive Zika information directly from a health care provider, including when received over a mobile platform. CONCLUSIONS: There is an unmet need for accessible information on the sexual transmissibility of Zika for women of childbearing age, especially those who are pregnant or intending to become pregnant. Given the ongoing risk for a future Zika outbreak in southern Arizona or elsewhere in the U.S.-Mexico border region, the preemptive development of effective information dissemination tools is warranted. In the context of preventing sexual Zika transmission, additional focus groups with Spanish-speaking, Mexican-origin women in southern Arizona will provide in-depth insight into potential barriers to sustained sexual behavioral changes and may identify risk and protective factors that can be leveraged in mHealth Zika prevention. This exploration should also consider the risk of sexual coercion and intimate partner violence in the development of effective Zika prevention messaging. Beyond focus groups, WhatsApp has strong potential for use in health promotion research and implementation among global populations with smartphone access, especially if healthcare professionals are involved.