Background Digital technologies may improve sexual and reproductive health (SRH) across diverse settings. Chatbots are computer programs designed to simulate human conversation, and there is a growing interest in the potential for chatbots to provide responsive and accurate information, counseling, linkages to products and services, or a companion on an SRH journey. Objective This review aimed to identify assumptions about the value of chatbots for SRH and collate the evidence to support them. Methods We used a realist approach that starts with an initial program theory and generates causal explanations in the form of context, mechanism, and outcome configurations to test and develop that theory. We generated our program theory, drawing on the expertise of the research team, and then searched the literature to add depth and develop this theory with evidence. Results The evidence supports our program theory, which suggests that chatbots are a promising intervention for SRH information and service delivery. This is because chatbots offer anonymous and nonjudgmental interactions that encourage disclosure of personal information, provide complex information in a responsive and conversational tone that increases understanding, link to SRH conversations within web-based and offline social networks, provide immediate support or service provision 24/7 by automating some tasks, and provide the potential to develop long-term relationships with users who return over time. However, chatbots may be less valuable where people find any conversation about SRH (even with a chatbot) stigmatizing, for those who lack confidential access to digital devices, where conversations do not feel natural, and where chatbots are developed as stand-alone interventions without reference to service contexts. Conclusions Chatbots in SRH could be developed further to automate simple tasks and support service delivery. They should prioritize achieving an authentic conversational tone, which could be developed to facilitate content sharing in social networks, should support long-term relationship building with their users, and should be integrated into wider service networks.

A working alliance (WA) is a multidimensional construct signifying a collaborative relationship between a client and a therapist. Systematic reviews of therapies to treat depression and anxiety, almost exclusively in adults, show WA is essential across psychotherapies. However, there are critical gaps in our understanding of the importance of WA in low-intensity therapies for young people with depression and anxiety. Here, we describe an initiative to explore the effect of WA on anxiety and depression outcomes in youth aged 14–24 years through a scoping review and stakeholders’ consultations (N = 32). We analysed 27 studies; most were done in high-income countries and evaluated one-on-one in-person therapies (18/27). The review shows that optimal WA is associated with improvements in: relationships, self-esteem, positive coping strategies, optimism, treatment adherence, and emotional regulation. Young people with lived experience expressed that: a favourable therapy environment, regular meetings, collaborative goal setting and confidentiality were vital in forming and maintaining a functional WA. For a clinician, setting boundaries, maintaining confidentiality, excellent communication skills, being non-judgmental, and empathy were considered essential for facilitating a functional WA. Overall, a functional WA was recognised as an active ingredient in psychotherapies targeting anxiety and depression in young people aged 14–24. Although more research is needed to understand WA’s influence in managing anxiety and depression in young people, we recommend routine evaluation of WA. Furthermore, there is an urgent need to identify strategies that promote WA in psychotherapies to optimise the treatment of anxiety and depression in young people.

BACKGROUND Digital technologies may improve sexual and reproductive health (SRH) across diverse settings. Chatbots are computer programs designed to simulate human conversation and there is a growing interest in the potential for chatbots to provide responsive and accurate information, counselling, linkages to products and services, or a companion on a SRH journey. OBJECTIVE We conducted a realist review that aimed to identify assumptions about the value of chatbots for SRH and collates the evidence to support them. METHODS We used a realist approach that starts with an initial program theory and generates causal explanations in the form of context-mechanism-outcome configurations (CMOCs) to test and develop that theory. We generated our program theory, drawing on the expertise within the research team, and then searched the literature to add depth and develop this theory with evidence. RESULTS The evidence supports our program theory, which suggests that chatbots are a promising intervention for SRH information and service delivery, because chatbots offer anonymous and non-judgmental interactions that encourages disclosure of personal information, complex information in a responsive and conversational tone that increases understanding, links to SRH conversations within online and offline social networks, immediate support or service provision 24/7 by automating some tasks and signposting to services, and have the potential to develop longer term relationships with users who return over time. However, chatbots may be less valuable where people find any conversation about SRH (even with a chatbot) stigmatizing, for those who lack confidential access to digital devices, where conversations do not feel natural and where chatbots are developed as standalone interventions without reference to social contexts. CONCLUSIONS Chatbots in SRH could be developed further to automate simple tasks and support service delivery, should prioritize achieving an authentic conversational tone, should be developed to facilitate content sharing in social networks, should support longer term relationship building with their users and should be integrated into wider service networks.

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Background: A working alliance (WA) is a multidimensional construct signifying a collaborative relationship between a client and therapist. Systematic reviews of therapies to treat depression and anxiety, almost exclusively in adults, demonstrate that WA is essential across psychotherapies. A functional WA predicts greater uptake of interventions, client engagement, adherence to treatment, and symptoms reduction. Conversely, ruptured and/or low WA reduces the effectiveness of known-efficacious treatments. However, there are critical gaps in our understanding of the importance of WA in low-intensity therapies for young people with depression and anxiety. We sought to understand the following research questions in young persons aged 14-24 years: 1) the role of working alliance in the ongoing management of anxiety and depression? 2) how do the different working alliance elements influence treatment outcomes?3) the client/therapist characteristics deemed essential in forming and maintaining a working alliance? Methods: We conducted a scoping review to summarise and synthesise the findings collaboratively with young people with lived experiences of anxiety/depression. Then, we conducted key stakeholders' consultations with clinicians [lay health counsellors (n=6), clinical psychologists (n=2), occupational therapists (n=2), and psychiatrists (n=2)], and young people with lived experiences (n=20). Finally, we convened workshops to triangulate/synthesise findings from the scoping review and stakeholder consultations to develop the mechanistic framework, hypothesising pathways by which WA may influence treatment outcomes. Results: We analysed 27 studies; most were done in high-income countries. Cognitive behavioural therapy was the most common treatment modality (16/27). Most therapy sessions were conducted one-to-one (18/27), with only two (2/27) studies utilising digital therapy platforms. A functional working alliance was recognised as an active ingredient in psychotherapies targeting anxiety and depression in young persons aged 14-24 years. Previous research has theorised that improvements in the working alliance are associated with improvements in relationships, self-esteem, positive coping strategies, optimism, adherence to treatments, and emotional regulation. During the stakeholders’ consultations, young people with lived experience expressed that; a favourable therapy environment, regular meetings, collaborative goal setting and confidentiality were vital in forming and maintaining a functional WA. For a clinician, ssetting boundaries, maintaining confidentiality, excellent communication skills, and being non-judgmental and empathic were considered important for facilitating a functional WA.Conclusions: Although more research is needed to understand WA's influence in managing anxiety and depression in young people, we recommend routine evaluation of WA. Furthermore, there is an urgent need to identify strategies that promote WA in psychotherapies to optimise the treatment of anxiety and depression in young people.