A mixed-methods study comparing digitized versus paper-based tools during the provision of sexual and reproductive health services for young women in Ethiopia

Adolescent girls and young women (AGYW) in Ethiopia face persistent barriers to accessing quality sexual and reproductive health (SRH) services, including limited information, stigma, and lack of youth-responsive care. This study aimed to compare the efficacy of digitized versus paper-based counselling tools within an intervention designed to address behavioral and structural barriers contributing to low contraceptive use among AGYW, by reframing contraception as a tool to achieve their life goals. The study employed a cross-sectional mixed-methods design, including client exit interviews with 302 AGYW, key informant interviews with 18 Health Extension Workers (HEWs), secondary analysis of service delivery data from DHIS2, and costing data from program records. Quantitative data were analyzed using descriptive statistics and chi-square tests. Qualitative data were thematically analyzed. Digital counselling was significantly associated with higher MII Plus scores (93% vs. 73.8%, p=0.001), client knowledge of side effects, and confidence in discussing and managing contraception. Clients rated paper-based tools as easier to understand, but digital tools enhanced comprehension, goal-setting, and integration of financial planning and reproductive health concepts. HEWs reported improved consistency in counselling, better referrals, and operational efficiencies with digital tools. Challenges included device glitches, limited connectivity, and variable digital literacy, often requiring concurrent use of paper and digital tools. This study shows that transitioning from paper-based to digital counselling tools improved service quality, client engagement, and informed contraceptive decision-making. Higher MII Plus scores and positive client experiences indicate more standardized, participatory, and respectful counselling. Providers reported operational benefits, including easier counselling and improved data management, though productivity gains were limited. Implementation challenges highlight the need for context-sensitive strategies, ongoing training, and supportive supervision during digital integration. Importantly, the findings suggest that digital tools can improve how services are delivered (quality and consistency), even when service volume remains stable.