Shifra: Refugee Sexual and Reproductive Healthcare App

Many refugees have immediate sexual and reproductive health needs that arise from a loss of contraception access, an increase in exposure to sex trafficking, higher risks of sexual assault, poor access to inclusive healthcare and safe birthing practices. 

Shifra knows that a world where every woman has access to high quality sexual and reproductive healthcare is possible. Our mission is to provide women from non-English speaking backgrounds equitable and discreet access to this information and services using digital technology. We create awareness and localise the issue of unmet sexual and reproductive health needs for women from all refugee and migrant backgrounds.

Shifra aims to discreetly connect women to respectful and evidence-based healthcare information in a format and language they understand. Shifra also utilises its anonymous data to work with healthcare professionals, policy makers and funders to better respond to the specific SRH needs of users by location and language. 

Australia resettled 22,398 Arabic-speaking refugees from Syria and Iraq between 2015 and 2017. Women and children made up over three quarters of this population, and most experienced poor access to sexual and reproductive healthcare (SRH), including family planning, pregnancy care, and trained birth attendants prior to their arrival in Australia. Inadequate SRH care not only endangers lives, it also reduces access to higher education and jobs, affects autonomy, independence and, ultimately, may restrict long-term community integration and civic participation. For women who have been resettled into host countries, cost, language and cultural barriers, difficulty accessing or navigating transportation, and a generalised lack of awareness regarding what services are available are additional contributors to poor SRH outcomes.

Improved access to SRH healthcare benefits the entire community, yet in both stable and unstable settings, these services are often limited, difficult to access or completely absent. Where SRH-related services are addressed, most programs focus upon the reproductive elements including family planning and perinatal healthcare, at the expense of sexual health needs such as information on sexuality, gender identity, support for sex workers or the SRH needs of older adults and people living with disability.

Shifra works with refugee communities to:

1. Undertake intersectional research to establish baseline demographics and pre-existing knowledge of and literacy surrounding SRH information and support services.  

2. Undertake mixed-methods, community-based participatory research (CBPR) to:

• detail self-identified barriers and enablers to SRH access;
• map quality, known and trusted SRH services and information.               

3. Co-design the adaptation and localisation of the Shifra web-app to:

• ensure that end-users are the focal point of all design and implementation decisions and that this participatory experience is imbued with dignity, respect, and self-determination;
• assess its potential effectiveness in developing community SRH literacy for the most marginalised and underserved communities within the humanitarian settings;
• determine best practice guidelines for replication, scale, and sustainability of Shifra or similar digital health interventions in other low resource settings.

4. Measure app utilisation and determine its success in: 

• improving community health literacy surrounding SRH information and services; 
• assess self-reported changes in behaviour or SRH literacy through pre/post studies;
• undertake a cost-benefit analysis comparing Shifra with existing SRH health promotion initiatives focused on marginalised communities. 

Shifra’s currently has three main products & services:

Web-App

Shifra’s web-app provides information on SRH and locations of healthcare services in multiple languages. Shifra provides evidence-based information on:

• Healthcare services, systems, rights and access
• Family Planning
• Maternal and Newborn health
• Sexual Health inc. Sexuality, Gender Identity, STIs, Consent, Healthy Relationships and Sex Work 
• Community and Primary Health Services inc. Men and Women's Health, Children and Adolescent Heath and Wellbeing, Mental Health in connection to being a refugee or asylum seekers and Family Violence

Data

Shifra collects anonymous data from the web-app which provides insights into unmet SRH needs of local communities.

Advocacy

Shifra creates awareness around the barriers new arrivals face in accessing healthcare services and works with local communities to overcome those barriers. We work with local organisations and health networks to improve their reach and ability to respond to specific needs of their health consumers. 

Shifra was co-designed and piloted with multiple Arabic-speaking migrant and refugee communities in Melbourne, Australia. Shifra is affecting meaningful service and policy change and helping to reduce resource wastage by listening to, learning from and working with the local communities most affected by inaccessible and chronically underfunded SRH services. Shifra engages local health professionals who are aligned to our mission, to work with us, validate our information and improve access to local, reputable health services.

We know that genuinely including and co-designing health solutions with end-users ensures higher utilisation rates, viability and sustainability of both the partnership and the solution. More importantly, communities that are listened to and engaged, particularly those who experience systemic disadvantage, experience greater improvements in both health and positive health behaviour change.

Shifra’s also provides indirect return on investment for partners through the costs-savings related to improved uptake of SRH services.  Long-term increase economic development of communities with access to these quality services is well-researched. In 2017, the Guttmacher Institute, one of the world’s leading SRH rights research and policy organisations, assessed the cost-effectiveness of providing comprehensive Contraception and Maternal and Newborn Health to all women who seek it. They found that implementing World Health Organisation-standard care would have the following effect:

• unintended pregnancies would drop by 75%
• maternal deaths would drop by 64%
• newborn deaths would drop by 76%.

Guttmacher also found that the cost of fully met these SRH needs of women in low and middle income countries was only $8.56 per person p.a..

• Shifra was built using React.js and Gatsby.js. 
• We use the Contentful CMS and are currently hosted on a Amazon Web Services’ cloud platform.
• We have sourced a service location API from InfoXchange, a social enterprise that specialise in “Technology for Social Justice”.

Access to quality, respectful sexual and reproductive health information is lacking for most refugees across the globe. This includes a loss of contraception access, an increase in exposure to sex trafficking, increased risk of sexual assault, and poor access to prenatal health care and safe birthing practices. In many crisis settings, the health and safety of women and girls are overlooked and accessing both comprehensive and quality information in their own language is virtually non-existent.

Shifra is a web-app designed to improve access to quality sexual and reproductive health care. It provides local, evidence-based health information in multiple languages for communities with varying levels of language and health literacy. Shifra also directs users to trusted clinics where they can access respectful and safe care.  

Shifra demonstrates capacity to meet users where they are and Shifra’s user market grows exponentially and sustainably based upon the cyclical health needs of its audiences. A user in need of pregnancy information and support, will soon move on to need neonatal and early childhood information. As their child grows they may plan to space their next baby, have more children immediately or prevent future pregnancies altogether. They may also seek information on mental health services, family violence information or insurance access depending on their situation and that of their family and friends around them. Shifra becomes the user’s trusted health guide throughout their reproductive life cycle which for most people averages 30-35 years. 

Please see out Conceptual Model for Social Return on Investment here. 

We currently reach up to 100 people a month. We expect to reach up to 1000/month over the next year as we have a pilot project planned with a major tertiary hospital which has three maternity units spread out over Melbourne's SW suburbs. This hospital network sees 10,000 women give birth each year. This hospital network also feeds into over 50 different maternal child health (MCH) clinics throughout the region. 

Community members and organisations directly involved in this research project will feel safe, heard and respected for their input and participation in community service mapping and co-design sessions. They will also feel recognised for their experiences and expertise navigating healthcare systems within humanitarian settings.

At a local level, the sexual and reproductive health content they co-design will provide touchpoints that help improve health literacy and agency surrounding healthcare decision-making and choice for other refugees and citizens within this setting.  

At a societal level, refugees and citizens will be able to access quality, evidence-based and accessible sexual and reproductive health information that contributes to their overall health and wellbeing. This information will be available online, in a discreet manner that helps build upon data surrounding the unmet sexual and reproductive health needs of people who live at the intersection of being further marginalised within a humanitarian crises.  

1. Replicate into Dari and reach national Arabic and Dari-speaking communities  
2. Evaluate pilot project in Melbourne hospital and MCH settings
3. Replicate in Farsi, Pubjabi, Hindi, Urdu, Vietnamese, Mandarin, Tamil, Somali, French and Spanish.  
4. Extend national reach inc. Aboriginal and Torres Strait Islanders communities
5. Replicate overseas within lower resource and rural/remote regions inc. crisis settings.

• We lack a proven, sustainable financial model. 
  • We are fortunate to have the technical, legal, language, cultural and market expertise within our team. 
  • Technical and language support has been paid for at heavily discounted rates, and legal and market experience has been generously donated.
• It costs approximately $50,000USD per language community/location we replicate into and takes 6-8 weeks to replicate Shifra once relationships have been established. 
• We have partners throughout Australia and internationally ready to support community co-design of implementation and localisation however we need funding to cover associated costs. 

• The Shifra team is working on cost-effective modelling and analysis with academics with the Monash University Business School and the Monash School of Public Health.
• Shifra is also an ideal conduit for ethical advertising, affiliate and influencer marketing sales, licensing and white-labelling, sponsorship, sales (subscriptions, goods/services, data), content-based training and online health education webinars for partner companies.

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• 1 Full time staff member
• 2 Part time staff members
• 7 contractors
• 5-7 Pro Bono Support

Shifra was founded and is led by Rebeccah Bartlett, a Registered Nurse-Midwife. Rebeccah is undertaking her PhD research on co-designing mHealth interventions with refugee and migrant communities at Monash University. She is a leader in reducing health disparities in underserved communities and promoting respectful maternity care. REbeccah has volunteered in rural/remote Australia, the Philippines, PNG and the US. 

Rebeccah has worked with Dr Jacqueline Boyle at Monash Centre for Health Research and Implementation to evaluate Shifra’s public health impact for the past 18 months. She has also partnered with Sylaba Translations to ensure all content is translated appropriately and in a culturally-sensitive manner. Finally, Shifra has worked with Lauren and the team at Your Creative to develop Shifra’s innovative technology. A leading data strategist and recipient of the 2019 Telstra Emerging Leader Award, Lauren is redesigning the way company’s see and use data. Lauren has experience creating intelligent user experiences across a range of industries including construction, technology and financial services.  

This team uses mixed-methodologies including community-based participatory research, anthropological and geographic-based inquiry, design thinking workshops and basic health and technological literacy questionnaires to determine the social and spatial influences to accessing health care that often goes unnoticed using traditional data collection methods. Grounded in the socio-ecological model, we employ an intersectional feminist lens in all our approaches. 

Shifra currently works with:

1. Monash Centre for Health Research and Implementation (MCHRI) to evaluate Shifra's process and product and Monash Business School to increase Shifra's reach and sustainability.  
2. Sylaba Translations to undertake all language and cultural translations
3. Your Creative for technical design and development

Please see Shifra's Business Canvas Model here

Shifra is attempting to develop its business model and operate as a sustainable social enterprise. At the current time we have received $25,000USD in donations over 4 years and are dedicated to developing relationships and applying to all grants we are eligible for, both in Australia and overseas. 

As mentioned, Shifra is also an ideal conduit for ethical advertising, affiliate and influencer marketing sales, licensing and white-labelling, sponsorship, sales (subscriptions, goods/services, data), content-based training and online health education webinars for partner companies.

Shifra has partners in all stages of its design, implementation and evaluation process. We have support to work with multiple refugee communities and local health networks within Australia and globally, however we lack funding to develop the capacity of refugee communities so that they implement, iterate and evaluate Shifra and ensure it works with their particular setting. As we expand, we will be able to develop and refine our business model and guidance and expertise in this area is needed.

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 Research and Advocacy

• Women's Refugee Commission 
• WHO-IBP
• UNHCR
• UNFPA

Implementation and Evaluation

• International Rescue Committee 
• International Red Cross and Crescent Societies 
• Doctors Without Borders
• Care International

Funding and Sustainability Planning

• Bill and Melinda Gates Foundation 
• David and Lucille Packard Foundation
• Ethical banking or impact investment organisations 
• Accenture/KPMG

All of these organisations could help Shifra undertake its goals (needs assessments, process/impact evaluations and cost-benefit analyses) in each community setting it wishes to replicate in. They could also ensure Shifra is able to disseminate its research and strategic findings globally, at minimal cost or pro-bono. 

Their support is essential to scaling Shifra and to demonstrating its long term cost-effectiveness. Most importantly, it would mean Shifra is able to develop best-practices around working with end-user communities to ensure they are able to direct and manage their own health interventions. We would then be able to invest our time and energy into ensuring our staff and directors are skilled, diverse and supported to help make Shifra financially sustainable and a internationally recognised leader in the space of refugee reproductive rights and digital healthcare. 

The idea for Shifra was conceived by the desire to be able to connect end-users to SRH information that is evidence based and easy to understand AND to then use their anonymous data to model future health needs in humanitarian settings in order to meet this demand efficiency and cost-effectively. 

AI demonstrates tremendous capacity to help make these predictions in real-time. Shifra currently lacks the personnel expertise to harness this potential. This funding would assist our tech team to connect with experts in this field, build upon their existing skillset and develop a strategy that ensures we can best apply AI to meet Shifra's goals in a way that promotes the principles of beneficence and non-maleficence. 

We would specifically like to utilise AI to explore the connection between geolocation (no more granular than zip/postal code in urban areas and sub-camp region in refugee camps) and what specific health needs are being explored based on language and user demographic (gender, age). We would like to work with leaders in the field of AI such as MIT, IBM and Google etc. and with behavioural economists and anthropologists to ensure we remain a people company that uses tech for the greater good, not a tech company that uses people to turn a profit. 

Increasing gender parity in STEM and in particular, the pay parity of women in this area is a core value of Shifra. We believe that women bring insight and innovation that is often overlooked especially when those women are from migrant and refugee backgrounds. We are particularly focused on women (cis or transgender) and non-binary people joining our mission. We recognise the intersectionality of being LGBTQI+ and a refugee. 

Supporting women to overcome both gender and language/cultural barriers within STEM is important and necessary to a progressive society. This funding would support two women from refugee backgrounds to develop their fundraising, strategic management and digital design skills and in turn contribute to Shifra's diverse governance structure.  

Shifra recognises that women from non-English speaking refugee backgrounds are experts in their own culture, identity, circumstances and goals. This project seeks to develop with them, online and therefore freely-accessible and ubiquitous, sexual and reproductive health content that is engaging, evidence-based and respectful. By doing so, users should feel informed, safe and heard, whilst still maintaining their privacy and autonomy.

The Shifra will not only provide “touchpoints for increase health literacy and agency surrounding health decision-making and choice” but assist health services that share them to see what information users seek that they may not be verbalising in appointments because they don’t feel comfortable asking, they may not be aware the information is useful to them, or they simply may not know it exists. Evaluating the app usage at a granular level will help local sexual and reproductive health services evolve to better meet the diverse needs of the women and families it serves.

To connect with non-English speaking communities, we need to work with local bicultural health workers who share a similar lived experience of the women we seek to reach. Their presence aids in building trust between the community developers and co-designers and the Shifra team. They also assist with translation of documents and interpreting social or cultural nuances that can also be misunderstood, overlooked or simply ignored by someone unfamiliar with the experience of humanitarian resettlement or working with non-English speaking communities. This funding will cover their costs and that of translating Shifra into 2-3 new languages.

Shifra co-designs both it process and products with refugee communities. We do this not just because it's the right thing to do ethically, but because this is what it means to be truly inclusive.

We know that those with lived experience are the best people to lead the direction and evaluation of this health innovation. This also helps develop the professional capacity and social capital of new arrivals when entering the workforce of their host country. 

This funding would help cover the costs of working with multiple bicultural health educators from refugee backgrounds to explore replicating and scaling Shifra's into specific refugee camps (both rural and urban). 

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