Priorities on trauma-informed design of sexual and reproductive health-related digital technologies: A modified nominal group technique

Abstract

Objectives

This study brainstormed and identified key priorities for integrating trauma-informed care (TIC) principles into the design and utilization of sexual and reproductive health (SRH)-related digital technologies.

Methods

We conducted a nominal group technique among interest holder groups in a large urban hospital in western Canada. The study occurred in four stages, (1) an introduction to the topic, (2) ideas generation, (3) in-person workshop, and (4) ideas ranking related to (i) SRH domains, (ii) population groups, and (iii) TIC approaches that should be prioritized in the design of health technologies. The data was analyzed using summative content analysis to produce a list of items, which were ranked and analyzed descriptively.

Results

Twenty people took part in this study. The findings emphasized the need to center stigmatized and emotionally sensitive SRH domains such as abortion, contraception, and STI care and called for technological design to prioritize inclusivity for marginalized groups such as 2SLGBTQIA+ individuals, migrants, sex workers, and those with low socioeconomic status. The participants proposed approaches such as customizable user interfaces, opt-in/opt-out engagement, multilingual support, content warnings, privacy controls, and survivor codesign for consideration when designing SRH digital health interventions.

Conclusion

This study highlights the urgent need to integrate TIC principles into digital technologies that are used to access highly stigmatized SRH services while centering the voices of marginalized populations in the codesign process. Despite the challenges in engaging trauma survivors in codesign, the trauma-informed design approaches identified can help create safe, empowering, and healing digital spaces for people with lived experiences of trauma.

Keywords

Trauma-informed design digital health sexual health and reproductive health nominal group technique underserved populations

Background

A number of digital health technologies have shown promise as innovative platforms to enhance access to sexual and reproductive health (SRH) services.¹ Digital health technologies refer to the use of information and communication technologies (i.e. mobile health, wearable devices, telehealth and telemedicine, web-based platforms, and personalized medicine) for improving health and wellbeing.² These technologies are particularly relevant for SRH issues that patients often consider embarrassing, stigmatizing, and difficult to discuss in face-to-face encounters. However, concerns exist regarding potential unintended consequences when implementing these technologies in the context of sensitive SRH topics. These concerns include issues such as re-traumatizing end-user patients, particularly for people who have experienced traumatic events in the past.^3,4 Exposure to trauma is consistently associated with poorer SRH outcomes, such as increased risk of sexually transmitted infections (STIs), unintended pregnancies, and chronic pelvic pain.⁵ For individuals with histories of trauma, sexual healthcare encounters can be physically and situationally triggering, potentially discouraging health-seeking behaviors such as participation in cervical screening.⁶

For the purposes of this study, trauma is used to describe the challenging emotional and psychological consequences an individual may experience after going through a distressing event.⁷ Trauma is pervasive, and it is estimated that approximately 70% of people across the globe will experience some traumatic event during their lifetime.⁸ Given this high percentage, it means that many patients who use technologies for SRH services may have prior trauma or ongoing experiences of trauma.⁹ Emerging evidence suggests that digital health technologies can be a source of trauma, particularly among marginalized populations, including ethnic minorities, sex workers, 2SLGBTQIA+ people and survivors of interpersonal violence.^10–16 Such trauma can be intentionally perpetrated by harmful online behaviors or unintentionally caused by elements of the digital interface that evoke memories of past negative experiences.¹⁷ For example, digital health technologies that expose individuals to cybercrimes such as online scams, sextortion, identity theft, or cyberbullying can lead to psychological distress, and in severe cases, suicidal ideation.⁴ Social media platforms and algorithmic systems have also inadvertently exposed sensitive personal information, such as outing 2SLGBTQIA+ individuals without their consent, leading to feelings of vulnerability and distress.^12,14 Even frequent security notifications or confronting graphic content online in sexual health-related technologies, can inadvertently retraumatize users by triggering memories of past traumatic events.¹⁸ Emerging evidence also indicates that SRH-related harms can arise through digital technology design features (e.g. navigation challenges, data or security breaches, inappropriate content display) as well as through digital-technology–mediated interpersonal interactions, such as targeted campaigns and depersonalized digital health communication.¹⁹

Even though technology-related trauma can occur in all sort of digital health interventions, its impact on patients who seek SRH services is particularly profound due to the deeply sensitive and stigmatized nature of issues such as sexuality, menstruation, STIs, and HIV/AIDS.^20,21 The private nature of these topics has the potential to exacerbate feelings of vulnerability, especially when there are concerns surrounding data mismanagement or exposure. Recent evidence from our work shows several digital health interventions that were designed to reduce and manage stigma ended up unintentionally reinforcing it.²² It has also been shown that survivors of violence who turn to digital health technologies for contraceptive services may encounter retraumatization when algorithms present them with triggering content or inappropriate advertisements.^9,15,23,24 Some menstrual tracking apps have also been found to reduce privacy, reinforce normative gender roles, position women as primarily reproductive citizens and create a disconnect between women and their bodies and/or intimate relationships.²⁵ Furthermore, concerns regarding the storage and management of personal health data, equitable access, informed consent, and technology regulation can heighten fear, apprehension, and anxiety among patients as they worry about the potential misuse of their sensitive health information.^26,27 Such concerns may not only erode trust in digital health interventions but also exacerbate feelings of vulnerability and emotional distress, reducing the likelihood of app engagement while undermining the effectiveness of digital health interventions. For marginalized populations such as survivors of sexual violence, sex workers, 2SLGBTQIA+ individuals, and (il)legal migrants, technology can amplify existing inequities in access to SRH services.²⁸

The high prevalence of trauma, coupled with the potential for retraumatization through digital health technologies, underscores the need for SRH technologies to be designed and implemented with an understanding of, and responsiveness to, trauma. This approach, known as trauma-informed design, is beginning to gain ground as researchers began exploring ways to mitigate technology-related trauma among patients.^3,9,29–32 Despite these initial efforts, this field lacks clear direction regarding the best and most meaningful ways to integrate trauma-informed care (TIC) principles into digital health technologies. Working collaboratively with an interdisciplinary interest holder group, the current work sought to identify priority areas related to trauma-informed design of SRH technologies. Trauma-informed design is being defined as an ongoing commitment to improve the design, development, deployment, and support of digital technologies by explicitly acknowledging trauma and its impact, recognizing that digital technologies can both cause and exacerbate trauma, and actively seeking out ways to avoid technology-related trauma and retraumatization.⁹

Methods

We used a modified nominal group technique to engage expert clinicians, patient partners, researchers, and software engineers in an in-person workshop. The workshop was conducted in a seminar room at a teaching hospital in a large metropolitan city in western Canada. A nominal group technique is a collaborative decision-making process used by a group of experts to elicit priorities and reach consensus related to a particular topic of interest.³³ A nominal group technique was chosen because it offers a discussive and democratic process for identifying and reaching a consensus while allowing ideas to emerge organically without imposing any preconceived views or analytical framework on the participants.³⁴ Most nominal group techniques involve four main stages, including (i) an introduction to the topic, (ii) idea generation, (iii) discussing/clarifying ideas, and (iv) ranking of ideas. All the stages of a nominal group technique are typically held in a single in-person workshop. However, we modified this approach by expanding the activities over three days. This modification not only gave participants more time to reflect on their ideas before meeting with the other group members but also reduced the time needed for an in-person meeting. A schematic presentation of the nominal group process is depicted in Figure 1. The study was approved by the University of British Columbia Behavioral Research Ethics Board (Approval ID, H24-00226). All participants provided written informed consent prior to participation, and the study was conducted between April and November 2024.

Figure 1.

Schematic presentation of the nominal group process.

Participants and recruitment

We held a nominal group technique with four different interdisciplinary interest holders who are known to play a critical role in the design and/or the utilization of digital health interventions. The purpose of this engagement was to brainstorm and identify priorities in trauma-informed design of digital health technologies. These stakeholder groups include (1) five SRH clinicians (doctors, nurses), (2) five patient partners, (3) five software designers and engineers, and (4) five researchers/clinician scientists. The clinicians, researchers, and software designers were recruited through the professional networks of the authors, while the patient partners were recruited using purposive and snowball sampling techniques. To be eligible for inclusion, the patient partners must have identified as coming from an underserved population (e.g. migrant, 2SLGBTQIA+, Indigenous, refugee or victims of sexual and gender-based violence, having a physical disability, or in a low socioeconomic status), have an experience in SRH, must have experienced an event in the past they consider to be emotionally distressing, and must have used digital health technologies to access SRH services using digital health. Patient partners with active emotional distress were excluded following a screening process using the Generalized Anxiety Disorder Scale.³⁵ For clinicians to be included, they must be persons who provide SRH services such as contraception, STI testing and counseling, and sexual functioning. They must have also used digital health technologies, such as telemedicine, web-based platforms, or video visits, to provide SRH services at some point in their careers. For software designers to be included, they must have been involved in the design of a digital health technology. For a researcher to be included, they must have been actively engaged in research on the topics of digital health, TIC, and/or sexual health.

Study procedures

Consistent with prior nominal group techniques,^33,34 this study occurred in four main stages. These include (1) introduction to the topic of trauma and TIC in technology design, (2) independent ideas generation, (3) in-person workshop to refine and consolidate the ideas and, (4) ranking of the ideas. Each stage of the nominal group technique is described below.

Stage I: Introduction

We recognized that our participants have diverse backgrounds and experiences and might not have been familiar with the three topics included in this study (i.e. trauma, TIC, and digital health). To ensure participants were familiar with the topics before the nominal group exercise, each person was provided with introductory materials via email and asked to review them in advance of the workshop. These materials were focused on TIC and the integration of TIC into the design and development of digital health interventions. The materials also contained conceptual definitions of terms, including trauma, trauma-informed design, and digital health technologies. In this study, we adopted the Center for Addiction and Mental Health definition of trauma as the challenging emotional consequences that an individual faces after living through a distressing event (sexual violence such as rape, physical assault the sudden loss of a loved one).³⁶ We defined digital health as technologies including mobile apps, health-related websites, wearable devices, telehealth, and telemedicine, that are used to facilitate access to or provide SRH services. Each participant was asked to review the study materials and to “seek for clarification” before data collection began. We provided an opportunity for a one-on-one meeting with each participant to clarify aspects of the reading materials that were unclear to them. During these meetings, an opportunity was provided for further questions on the study procedures, expectations, and requirements for each stage of the nominal group process. The introduction stage helped the participants familiarize themselves with the topic and set the stage for the subsequent phases. The data collection occurred in the subsequent three stages (during the ideas generation, the in-person workshop, and the rankings of ideas).

Data collection

The data collection occurred during the idea generation stage and continued until the ranking of the final set of ideas.

Stage II: Ideas generation

Following the review of the study materials and a one-on-one meeting with participants (where required), we asked them to independently generate ideas on how TIC can be incorporated into the design of digital technologies related to sexual health. We created and sent participants a form containing three main guiding questions. We also developed a set of guiding instructions and requirements to help participants provide informed feedback. Before completing the form, the participants were asked to reflect on the study materials as well as their lived experiences related to how digital health is; (1) used by clinicians to provide care, (2) used by patients to receive/seek care, (3) being developed by software engineers, and (4) being investigated by researchers. Based on the readings and lived experiences, participants then responded to three guiding topics specified below:

Areas of sexual health and reproductive health that should be prioritized for trauma-informed design of digital technologies

Population groups that should be prioritized for trauma-informed design of digital technologies

Aspects of TIC that should be considered and prioritized when designing SRH digital technologies

Weekly reminders were sent to every participant and all the 20 participants returned their written feedback via email within three weeks. These responses were analyzed, and the findings provided a preliminary list of participants’ ideas on the three main thematic areas. These preliminary ideas were used as a guide during the in-person workshop. While this independent ideas generation does not often occur in a typical nominal group exercise,³⁷ we adopted this approach to enable participants to generate their ideas independently of other participants while reducing the influence of highly vocal participants on less vocal ones. This approach was also better suited to the time constraints of the in-person workshop (see Supplemental Materials for the ideas collation form and the guidelines to the nominal group workshop).

Stage III: In-person workshop

All 20 participants convened in-person in a large healthcare facility in Western Canada. Participants formed four groups of five, with each group comprising at least one clinician, one patient partner, one researcher, and one software engineer. Each group was assigned a moderator. There was also an overall moderator who oversaw the entire workshop. The event moderator introduced the day's agenda and then delivered a 10-min presentation on the topic of trauma, trauma-informed design, and digital health. A summary of the findings from the ideas generation stage described above (Stage II) was also presented to the participants, followed by an opportunity for questions and answers (Q/A). The participants were then assigned to their respective groups. Each group selected a leader, a scribe, and a spokesperson. The group leader led a discussion of the three main guiding questions that were posed to the participants in the ideas generation phase (the aspects of TIC, the sexual and reproductive areas, and the population groups that should be prioritized when designing SRH digital technologies). As the discussions progressed, each group member wrote additional ideas on sticky notes or refined their preliminary ideas generated in the prior phase. These new/revised ideas were then posted on a notepad board designated for each group. The group leaders then took turns discussing the submissions from their group members, focusing on how those ideas reflected the three guiding questions. As the discussions progressed, additional ideas were identified; some were merged, while redundant ideas were removed. The in-person workshop lasted 6 h (10 a.m. to 4 p.m.). Following the discussions, the data (participants’ sticky notes) were analyzed thematically. The analysis process is described in the following section.

Data analysis

The ideas generated in stages II and III were analyzed using summative content analysis.³⁸ Summative content analysis is a form of content analysis that involves identifying and quantifying certain words or text to understand the contextual use of words or statements. This content analysis process was used because it enables the analysis of varied textual data and has also been recommended for analyzing data involving group consensus-building exercises.³⁹ During the analysis process, two team members reviewed the presentation and notes from each group. Next, an affinity diagram was used to organize the ideas, represented by the sticky notes, by grouping and regrouping them under their respective guiding questions (please see Supplemental Materials for the affinity diagrams).⁴⁰ The sticky notes under each guiding question were then analyzed thematically by organizing, revising, and regrouping the sticky notes based on their relevance to each of the guiding questions.

Additionally, for the third guiding question (Aspects of TIC that should be prioritized when designing SRH digital technologies), we specifically adopted a deductive analysis approach based on the Substance Abuse and Mental Health Services Administration's (SAMHSA) Principles of TIC Framework.¹⁸ By adopting this framework, we grouped sticky notes based on their relevance to each of the six areas of the SAMHSA TIC framework (safety, trust, peer support, collaboration, empowerment and choice, and cultural/historical/gender issues). For each of the guiding questions, a list of ideas was then generated from our thematic analysis and was subsequently deployed to all participants for ranking.

Stage IV: Ranking of ideas

The ideas from the in-person workshop were ranked anonymously by the participants to identify a priority list from the overall ideas. The purpose of the ranking was to identify the most important areas of SRH, the most important population groups, as well as the most critical trauma-informed approaches to consider in the design of SRH-related digital technologies. The ideas were presented to participants through a UBC-accredited Qualtrics survey. For each category (i.e. SRH areas, population groups, and TIC approaches), participants were asked to select the items they considered to be the highest priority. Items selected first were considered the highest priority, whereas those selected later were treated as lower priority relative to the earlier choices. The ranking exercise occurred in November 2024—two months after the in-person workshop.

Statistical analysis of ranked ideas

The ranked ideas were analyzed using mean and standard deviation. Ideas ranked at the top of each category were considered to be the most preferred, while those ranked at the bottom were considered the least preferred relative to the first ones. This ranking translated to a lower mean score for highly prioritized ideas and a higher mean score for less prioritized ideas.

Results

A total of 20 participants took part in the first three stages of the nominal group exercise. However, only 12 participants completed the final ranking of ideas and eight were lost to attrition. The participants had varied expertise and lived experiences. The clinicians had expertise in sexual functioning, STI treatment, and contraception. The researchers who participated in the workshop specialized in digital health across various clinical areas, including SRH, wound care, and patient safety. The technology developers were mainly software designers and engineers with a focus on digital health technologies. The patient partners had diverse minoritized identities, including a person with disability, Indigenous, Two-Spirit, and Queer identity. Our summative content analysis revealed five main ideas for the first guiding question, seven ideas for the second guiding question, and 26 ideas for the third guiding question. The 26 ideas under the third guiding question were further categorized under the SAMHSA principles of the TIC framework. The generated ideas in response to each of the guiding questions are provided in the following section.

SRH areas of focus for trauma-informed design

The participants generated five main ideas on topic areas related to SRH that should be prioritized in trauma-informed design of digital health technologies. Among the five ideas, SRH services like abortion, pregnancy, and infertility were ranked as the most important sexual and reproductive areas to be prioritized in digital technology design. The second most important area was STIs. Sexual health and sexual functioning, as well as contraception, ranked lower in this category. Table 1 presents the participants’ ideas on priority sexual and reproductive areas as well as their associated mean rankings, where lower mean scores indicate a higher ranking.

Table 1.

Sexual and reproductive health areas that should be prioritized for research in trauma-informed design.

No.	Ideas generated	Rankings mean (SD)
1	Reproductive health (abortion, pregnancy, and infertility)	2.1 (0.3)
2	Sexually transmitted infections (prevention, testing, treatment, education, and ongoing care)	2.5 (1.8)
3	Sexual and gender-based violence	2.6 (1.7)
4	Sexual health and sexual functioning (vaginismus)	3.8 (0.6)
5	Contraception	3.8 (0.9)

Population groups of focus for trauma-informed design

The participants also identified seven population groups that should be prioritized for trauma-informed design of digital health technologies. These population groups reflected people who may have had traumatic experiences or are likely to be exposed to traumatic situations in their lives. Among the population groups suggested, sexual and gender minority groups such as 2SLGBTQIA+ and asexual people were highly prioritized. This was followed by people with low socioeconomic status, then migrants and refugees, and subsequently, people with physical and mental disabilities. People who experience sexual and gender-based violence received the lowest priority in this category. Table 2 presents the prioritized population groups identified by the participants and their rankings.

Table 2.

Population groups that should be prioritized for research in trauma-informed design.

No.	Ideas generated	Mean rankings (SD)
1	Sex and gender minority groups (2SLGBTQIA+ and asexual people)	3.0 (2.0)
2	People with low socioeconomic status (single parents, the elderly, sex workers, and incarcerated people)	3.5 (1.8)
3	Migrants and refugees	4.0 (2.2)
4	People with physical, neurological, and mental disabilities	4.2 (1.0)
5	Racial minorities, including people of color, Indigenous people	4.2 (1.4)
6	People with uteruses	4.5 (2.0)
7	People who have experienced sexual and gender-based violence	4.5 (2.6)

TIC approaches in SRH digital technologies

The participants identified 26 TIC approaches that should be considered in the design and utilization of digital health technologies. These ideas reflected five of the six principles of the SAMHSA principles of TIC framework. None of the ideas was reflected under the principle of Cultural, Historical, and Gender issues. The 26 ideas comprised of six trauma-informed design approaches under Safety in digital technology platforms, five under Trust and Transparency in digital platforms, three under Collaboration and Mutuality in digital platforms, six under Empowerment within digital platforms, and six under Autonomy and Choice in digital health spaces. Under safety, clear guidelines that discourage harmful or triggering comments were highly prioritized. Under trust and transparency, data privacy and transparency were highly prioritized. Under collaboration, consultation with trauma survivors was highly rated. Controlling privacy settings and customization of digital health technologies were highly prioritized under empowerment and autonomy/choice, respectively. Table 3 provides more information on the number and ranking of the respective trauma-informed approaches under each of the five guiding principles of SAMHSA's framework. The mean scores for each category were based on the number of items for that category. For instance, the mean scores for safety on digital platforms were based on a score of 1–6 (i.e. six items), whereas the mean score for collaboration on mutuality was based on a score of 1–3 (i.e. three items).

Table 3.

Trauma-informed care approaches that should be integrated into the design of digital health technologies (using the SAMHSA principles trauma-informed care framework).

No.	Trauma-informed area	Trauma-informed care approach	Mean ranking (SD)
1	Safety in digital technology platforms	Clear guidelines that discourage harmful or triggering comments	2.2 (1.3)
		Informed consent with trauma survivors	2.7 (1.7)
		Controlling for assumptions and bias	3.2 (1.3)
		User privacy and confidentiality	3.7 (1.4)
		Trigger warnings	4.5 (1.5)
2	Trust and transparency in digital technology platforms	Data privacy and transparency	1.5 (0.5)
		Anonymity of technology users	2.2 (0.8)
		Transparency in data collection, storage, and use	2.2 (0.8)
		Regularly update users about changes to privacy policies and platform features	4.5 (0.5)
		Share how user feedback is incorporated into platform improvements	4.5 (0.5)
3	Collaboration and mutuality in digital technology platforms	Consultation and engagement with trauma survivors in codesigning a platform feature to meet their needs	1.2 (0.4)
		Creating avenues that connect patients with support personnel and resources	2.0 (0.7)
		Empower users to contribute as moderators or peer mentors	2.7 (0.4)
4	Empowerment within digital technology platforms	Allow users to control privacy settings and choose the level of interaction they are comfortable with	1.5 (0.5)
		Support throughout/regular iterative feedback loops	2.7 (1.4)
		Offer self-care and coping resources to empower users to manage their well-being	3.7 (1.3)
		Aftercare support	3.7 (1.9)
		Multi-media approaches	4.5 (0.8)
		Trauma coach	4.7 (1.3)
5	Autonomy and choice in digital health spaces	Customization in modalities and functionality	1.2 (0.4)
		Ease of patient access	2.7 (1.3)
		Provide opt-in/opt-out options for notifications and engagement	3.5 (0.8)
		Having different language options	3.5 (1.6)
		Allowing users to customize visual and sensory aspects	4.5 (0.8)
		Screener in digital health to identify those who have had trauma	4.5 (0.8)

Discussion

Using a modified nominal group technique, the current research identified and prioritized key considerations for the trauma-informed design of SRH-related digital technologies. Through structured engagement with four different interest holders, in an in-person workshop, we offered guidance across three interrelated domains in SRH: (1) specific SRH areas where trauma-informed approaches are most urgently needed, (2) population groups that require deliberate inclusion in design processes, and (3) principles of TIC that should underpin sexual and reproductive digital technology development. Among the topical areas identified, participants also emphasized the need to prioritize SRH domains that are stigmatizing, emotionally and physically traumatizing, including abortion care, sexual violence, and STI testing and treatment. These priority areas reflect how these reproductive health issues often intersect with histories of trauma, stigma, and marginalization^41–43 The intersection of trauma with these important SRH domains highlights the critical importance of information and healthcare delivery through digital platforms. In addition to the SRH areas, the findings also indicate the importance of considering specific population groups when designing trauma-informed SRH technologies. Even though trauma can affect people across all demographics,⁸ participants prioritized the needs of groups that often face systemic discrimination, exclusion, or harm within healthcare systems, including 2SLGBTQIA+ individuals, people with low socioeconomic status (single parents, elderly, sex workers, incarcerated people), and migrants and refugees.^44,45 While people living with disabilities and survivors of sexual and gender-based violence constitute groups that often disproportionately carry the burden of emotional trauma,⁴⁶ they were least prioritized compared to the other identified groups. This low prioritization may not necessarily indicate that sex- and gender-based violence is not a crucial consideration in trauma-informed design. Rather, it could be attributed to a limited representation of participants with lived experience of or expertise in sex and gender-based violence. Interestingly, the population groups identified in this study are more likely to opt for digital health interventions, partly due to the perceived stigma of seeking SRH services in conventional health settings.⁴⁷

The study also highlights the critical role of TIC approaches in guiding the design, development, and use of digital technologies for SRH. The TIC approaches that emerged from this study align with five of the six principles of the SAMHSA TIC framework, including Psychological Safety, Trust and Transparency, Collaboration, Empowerment, and Autonomy and Choice.¹⁸ The Principles of Cultural, Historical, and Gender issues did not reflect any of the approaches identified in the study. Even though these TIC principles have been adopted in SRH services like abortion, contraception, and sexually transmitted and blood-borne infections, they are often confined to conventional face-to-face settings.^41,48–50 This study extended these TIC approaches to include how they can be adapted and integrated into digital health technologies. To adapt and integrate SAMHSA principles of safety in digital health contexts, the participants identified and reached a consensus on the importance of embedding trauma-informed approaches in digital health design and use. Principles such as clear guidelines that discourage harmful or triggering comments or content, data privacy and transparency, allowing users to control privacy settings, engaging trauma survivors in developing digital health content, and choosing the level of interaction they are comfortable with during digital health interactions were highlighted among the participants. Ensuring emotional and psychological safety through content warnings and secure data practices was considered essential for preventing retraumatization, particularly on patient-centered educational web-based platforms. Even though content and trigger warnings have been used in other domains (e.g. education, audiovisual industries, games and apps, media studies, social media, music, and mental health),⁵¹ their benefits have been contested, with some evidence suggesting that content warnings may produce the opposite effect by raising anxiety and reinforcing traumatic experiences for end users.^52,53 Given the controversial nature of content warnings, further studies are needed to examine preferences for and appropriate ways to integrate content warnings on SRH-related digital platforms.

Consultation and engagement with end users, including trauma survivors in codesigning SRH-related digital platforms were identified and prioritized as an essential component in the creation of trauma-informed digital health solutions. Engaging with end-user patients in codesign enhances the relevance, responsiveness, usability, and acceptability of digital health interventions.^54–56 However, there are currently no evidence-based guidelines on how to meaningfully engage trauma survivors in a codesign process in a manner that minimizes the risk for retraumatization. Further studies are needed to explore appropriate and trauma-informed approaches for engaging with trauma survivors in the digital health design process. Participants also emphasized the importance of trustworthiness and transparency, especially regarding how data are collected, stored, and used, as such issues can retraumatize people who seek SRH services, particularly abortion.^41,57 Providing users choice and control over their engagement with digital health technologies, such as the ability to customize content or navigate at their own pace, was central to supporting patient-centered engagement. Approaches identified as a way of empowering people who seek SRH services include aftercare support for survivors, multimedia approaches, and integrating trauma coaches. Integrating trauma-informed approaches such as user interface customization features, ease of access, opt-in/opt-out engagement options, language diversity, and sensory customization has the potential to create a safe and supportive environment. Customization, for instance, can empower users to engage with SRH technologies on their terms, helping restore a sense of control often disrupted by traumatic experiences. Simplifying access ensures that survivors, particularly those from marginalized or underserved communities, are not further excluded due to digital or logistical barriers. Opt-in/opt-out options for notifications and interactions might allow users to regulate their emotional exposure and avoid unwanted triggers. Offering content in multiple languages might enhance cultural relevance and accessibility, while allowing users to adjust visual and sensory features, such as color themes, text size, or sound, might support individuals with trauma-related triggers. Similar customization strategies have been adopted in digital health technologies for seniors.⁵⁸ Even though an approach like screener in digital health to identify those who have had trauma was identified during the workshop, it received the lowest priority rating in the participants’ ranking. The lowest rating indicates that this approach was not favorable among the participants.

Implications for health technology design and utilization

The findings from this study underscore the need for embedding trauma-informed principles into the design and utilization of SRH technologies, particularly in domains such as abortion care, sexual violence, and STI testing and treatment, which are often stigmatized and closely tied to histories of trauma and marginalization.^59,60 Policy and decision makers, as well as digital health developers, should consider embedding features that reduce retraumatization into digital health technologies (e.g. confidential access, empathetic language, and nonjudgmental interfaces). Digital technologies should also be intentionally designed to provide clear pathways to supportive services, including counseling and referral options. This can be truly achieved if marginalized populations are centered in the design process or if cultural sensitivity, multilingual accessibility, and flexible design features that reflect diverse lived experiences are embedded in such technologies.^61,62 At the policy level, funders and project leaders should be encouraged to adopt trauma-informed frameworks when supporting SRH technology initiatives while training health providers to integrate TIC approaches into digital health pathways—ensuring continuity between digital and in-person services. Finally, close collaboration among technologists, healthcare professionals, and end-users should be prioritized in the design of technology interventions. Such collaboration is essential because no single group possesses all the expertise required to ensure the holistic development and effective use of digital health technologies.

Strengths of the study

By engaging with clinicians, software designers, researchers, and patient partners, we were able to gather diverse perspectives that reflect the relevant interest holder groups that are often involved in either the design or use of digital health technologies. Also, generating independent ideas before the in-person workshop, to a large extent, reduced the group dominance and the biases often encountered in a single nominal group exercise.⁶³

Limitations

Despite the strengths of the study, it is not without limitations. Specifically, the patient partners in the study were just five and might not have sought all SRH services. It is, therefore, possible that some population groups, SRH areas and trauma-informed approaches that did not reflect the study group might have been left out. Also, the final ranking of ideas was based on a sample of 12 out of 20 participants. Because the ranking process was conducted anonymously to minimize response bias, we were also unable to determine whether the 12 participants equitably represented the different interest holder groups in the study. Further studies on a larger and more diverse sample size would be needed to substantiate the ideas generated from this study. The study participants did not include adolescents population. Further studies are needed to examine this phenomenon among adolescents. Although this study was conducted in the context of SRH, we believe that the findings could be applied to technologies for other population groups with a disproportionate burden of emotional trauma and other health services/health issues that could be distressing.

Conclusion

Using a modified nominal group technique, this study engaged diverse interest holders to identify trauma-informed priorities in the design of digital technologies for SRH. The findings highlight priority SRH areas, vulnerable populations, and practical strategies aligned with TIC to enhance psychological safety, autonomy, and trust in digital health technologies. While challenges remain in meaningfully engaging trauma survivors in the codesign process, other strategies such as customizable, accessible, and culturally responsive digital features have the potential to transform SRH platforms into safe, empowering spaces that support healing and reduce retraumatization, particularly for those with lived experiences of trauma. While the ideas generated from this study are yet to be implemented, we believe that they look promising in ameliorating the effects of digital health technologies on end users’ emotional trauma.

Supplemental Material

sj-pdf-1-dhj-10.1177_20552076261431882 - Supplemental material for Priorities on trauma-informed design of sexual and reproductive health-related digital technologies: A modified nominal group technique

Supplemental material, sj-pdf-1-dhj-10.1177_20552076261431882 for Priorities on trauma-informed design of sexual and reproductive health-related digital technologies: A modified nominal group technique by Abdul-Fatawu Abdulai, Kaitlyn Goldsmith, Cerita Hartman, Kristie Nicol, Charlene Esteban Ronquillo, Chantelle Recsky, Ria Nishikawara, Rachel Ralph, Adrian Guta, Katrina N. Bouchard and Leanne Currie in DIGITAL HEALTH

Supplemental Material

sj-pdf-2-dhj-10.1177_20552076261431882 - Supplemental material for Priorities on trauma-informed design of sexual and reproductive health-related digital technologies: A modified nominal group technique

Supplemental material, sj-pdf-2-dhj-10.1177_20552076261431882 for Priorities on trauma-informed design of sexual and reproductive health-related digital technologies: A modified nominal group technique by Abdul-Fatawu Abdulai, Kaitlyn Goldsmith, Cerita Hartman, Kristie Nicol, Charlene Esteban Ronquillo, Chantelle Recsky, Ria Nishikawara, Rachel Ralph, Adrian Guta, Katrina N. Bouchard and Leanne Currie in DIGITAL HEALTH

Supplemental Material

sj-pdf-3-dhj-10.1177_20552076261431882 - Supplemental material for Priorities on trauma-informed design of sexual and reproductive health-related digital technologies: A modified nominal group technique

Supplemental material, sj-pdf-3-dhj-10.1177_20552076261431882 for Priorities on trauma-informed design of sexual and reproductive health-related digital technologies: A modified nominal group technique by Abdul-Fatawu Abdulai, Kaitlyn Goldsmith, Cerita Hartman, Kristie Nicol, Charlene Esteban Ronquillo, Chantelle Recsky, Ria Nishikawara, Rachel Ralph, Adrian Guta, Katrina N. Bouchard and Leanne Currie in DIGITAL HEALTH

Supplemental Material

sj-pdf-4-dhj-10.1177_20552076261431882 - Supplemental material for Priorities on trauma-informed design of sexual and reproductive health-related digital technologies: A modified nominal group technique

Supplemental material, sj-pdf-4-dhj-10.1177_20552076261431882 for Priorities on trauma-informed design of sexual and reproductive health-related digital technologies: A modified nominal group technique by Abdul-Fatawu Abdulai, Kaitlyn Goldsmith, Cerita Hartman, Kristie Nicol, Charlene Esteban Ronquillo, Chantelle Recsky, Ria Nishikawara, Rachel Ralph, Adrian Guta, Katrina N. Bouchard and Leanne Currie in DIGITAL HEALTH

Footnotes

Acknowledgments

We would like to acknowledge the endometriosis and pelvic pain lab and Vancouver General Hospital for providing the space for the in-person workshop.

ORCID iDs

Abdul-Fatawu Abdulai

Cerita Hartman

Charlene Esteban Ronquillo

Katrina N. Bouchard

Ethical approval and consent for participation

Ethical approval was obtained from the University of British Columbia Behavioral Research Ethics Board (H24-00226). Written, fully informed consent was obtained from all participants in adherence to the requirements outlined in the Declaration of Helsinki.

Author contributions

AFA conceptualized the study, obtained the funding, recruited the participants and wrote a draft of the manuscript. KG, CH, and LC organized and moderated the in-person workshop. KN, CR, CR, RN, RR, KB, and AG contributed to writing and reviewing the manuscript. All authors approved the final version of the manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Michael Smith Health Research BC Convening and Collaborating Grant (Grant No. GR029078).

Declaration of conflicting interests

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Data availability statement

The data for this study are not publicly available because they contained identifying information (names, images) of the participants.

Supplemental material

Supplemental material for this article is available online.

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