Following the trail of an HIV-prevention Web site enhanced for mobile cell phone text messaging delivery

Technology-driven methodologies to collect qualitative data among youth to inform HIV prevention and care interventions

The use of technology as a platform for delivering HIV prevention interventions provides an efficient opportunity to reach those at risk for HIV with targeted and timely prevention and treatment messages. Technology-delivered HIV interventions are becoming increasingly popular and include interventions that use mobile text messaging and mobile phone apps or deliver prevention messages through telehealth platforms. Community-centered approaches of intervention development can help address the potential gap between science and practice by ensuring that interventions are appropriate and driven by community needs and desires. Common approaches to gaining community input rely on qualitative data gathered through in-person focus group discussions (FGD), in-depth interviews (IDI) and youth advisory boards (YABs). While these proven methodologies have strengths, youth engagement can be limited by structural barriers (e.g., lack of transportation, inconvenient timing) and reluctance to participate due to stigma or discomfort with group settings. This results in a number of biases that limit the quality of face-to-face qualitative data collection, i.e., social desirability bias or selection biases created by differential likelihood of recruitment and attendance. As an increasing number of HIV prevention and care interventions are successfully delivered online, innovative approaches to youth engagement in virtual spaces can also be applied across the intervention lifespan to increase the quality and validity of formative data. In this paper, we describe a range of qualitative data collection techniques that can be used via online platforms to collect qualitative data, and we outline their relative advantages over face-to-face FGD or IDI. We use four case studies to highlight the methodologies and findings and provide recommendations for researchers moving forward.

Bringing Real-Time Geospatial Precision to HIV Surveillance Through Smartphones: Feasibility Study

BACKGROUND

Precise measurements of HIV incidences at community level can help mount a more effective public health response, but the most reliable methods currently require labor-intensive population surveys. Novel mobile phone technologies are being tested for adherence to medical appointments and antiretroviral therapy, but using them to track HIV test results with automatically generated geospatial coordinates has not been widely tested.

OBJECTIVE

We customized a portable reader for interpreting the results of HIV lateral flow tests and developed a mobile phone app to track HIV test results in urban and rural locations in Rwanda. The objective was to assess the feasibility of this technology to collect front line HIV test results in real time and with geospatial context to help measure HIV incidences and improve epidemiological surveillance.

METHODS

Twenty health care workers used the technology to track the test results of 2190 patients across 3 hospital sites (2 urban sites in Kigali and a rural site in the Western Province of Rwanda). Mobile phones for less than US $70 each were used. The mobile phone app to record HIV test results could take place without internet connectivity with uploading of results to the cloud taking place later with internet.

RESULTS

A total of 91.51% (2004/2190) of HIV test results could be tracked in real time on an online dashboard with geographical resolution down to street level. Out of the 20 health care workers, 14 (70%) would recommend the lateral flow reader, and 100% would recommend the mobile phone app.

CONCLUSIONS

Smartphones have the potential to simplify the input of HIV test results with geospatial context and in real time to improve public health surveillance of HIV.

Identifying Solutions to Improve the Sexually Transmitted Infections Testing Experience for Youth Through Participatory Ideation

Sexually transmitted infection (STI) services, including screening, treatment, and counseling among youth, remain suboptimal. In the midst of increasing incidence of bacterial STIs, alarming STI disparities, and persistently low testing rates among youth, solution-focused and action-oriented research with youth is needed. To identify solutions to STI testing barriers, we conducted three participatory ideation workshops with 18 youth, 10 key stakeholders who work with youth, and 8 social design graduate students. In response to prompt questions asking "How might we" address a testing barrier, participants generated as many ideas as they could on small pieces of paper. The brainstorming sessions produced 702 brainstorm idea sheets that were then qualitatively analyzed through pile sorting by three team members (including two youth) with each pile representing a priori themes (from the "How might we" probe) or emergent themes. Ten themes were identified corresponding to three domains: (1) improving the testing experience (improving transparency in the testing process, increasing trust in privacy, alternative testing options, and providing incentives/rewards for testing), (2) addressing the clinic space (multi-service spaces, appealing physical clinical space, and providing waiting room activities), and (3) reframing STI testing (normalizing STI testing, the clinic as a supportive environment, and youth leadership to promote and support STI testing). These findings move beyond identifying barriers and motivators to STI testing among youth and focus on the generation of possible solutions. By engaging youth in the development of solutions to STI testing, solutions that may be better-utilized and more acceptable to youth may be developed.

Using mobile technology to promote safe sex and sexual health in adolescents: current practices and future recommendations

Youth and young adults (19–24 years of age) shoulder the burden of sexually transmitted infections accounting for nearly half of all new infections annually. Mobile technology is one way that we have reached this population with safer sex information but challenges exist with the delivery process. The literature between 2010 and 2015 was reviewed for data on safe sex and sexual health information delivered using mobile cell phone devices. A search for relevant databases revealed that 17 articles met our inclusion criteria. Findings suggest that mobile cell phone interventions are an effective mode for delivering safe sex and sexual health information to youth; those at the highest risk may not be able to access cell phones based on availability and cost of the text messages or data plans.

Building a Mobile HIV Prevention App for Men Who Have Sex With Men: An Iterative and Community-Driven Process

BACKGROUND

Gay, bisexual, and other men who have sex with men (MSM) account for a disproportionate burden of new HIV infections in the United States. Mobile technology presents an opportunity for innovative interventions for HIV prevention. Some HIV prevention apps currently exist; however, it is challenging to encourage users to download these apps and use them regularly. An iterative research process that centers on the community's needs and preferences may increase the uptake, adherence, and ultimate effectiveness of mobile apps for HIV prevention.

OBJECTIVE

The aim of this paper is to provide a case study to illustrate how an iterative community approach to a mobile HIV prevention app can lead to changes in app content to appropriately address the needs and the desires of the target community.

METHODS

In this three-phase study, we conducted focus group discussions (FGDs) with MSM and HIV testing counselors in Atlanta, Seattle, and US rural regions to learn preferences for building a mobile HIV prevention app. We used data from these groups to build a beta version of the app and theater tested it in additional FGDs. A thematic data analysis examined how this approach addressed preferences and concerns expressed by the participants.

RESULTS

There was an increased willingness to use the app during theater testing than during the first phase of FGDs. Many concerns that were identified in phase one (eg, disagreements about reminders for HIV testing, concerns about app privacy) were considered in building the beta version. Participants perceived these features as strengths during theater testing. However, some disagreements were still present, especially regarding the tone and language of the app.

CONCLUSIONS

These findings highlight the benefits of using an interactive and community-driven process to collect data on app preferences when building a mobile HIV prevention app. Through this process, we learned how to be inclusive of the larger MSM population without marginalizing some app users. Though some issues in phase one were able to be addressed, disagreements still occurred in theater testing. If the app is going to address a large and diverse risk group, we cannot include niche functionality that may offend some of the target population.

mHealth: An updated systematic review with a focus on HIV/AIDS and tuberculosis long term management using mobile phones

OBJECTIVE

To evaluate the utilization of mobile phone technology for treatment adherence, prevention, education, data collection, monitoring long-term management of HIV/AIDS and TB patients.

METHODS

Articles published in English language from January 2005 until now from PubMed/MEDLINE, EMBASE, Web of Science, WHO databases, and clinical trials were included. Data extraction is based on medication adherence, quality of care, prevention, education, motivation for HIV test, data collection from HIV lab test results and patient monitoring. Articles selected for the analysis cover RCTs and non RCTs related to the use of mobile phones for long-term care and treatment of HIV/AIDS and TB patients.

RESULTS

Out of 90 articles selected for the analysis, a large number of studies, 44 (49%) were conducted in developing countries, 24 (26%) studies from developed countries, 12 (13%) are systematic reviews and 10 (11%) did not mention study location. Forty seven (52.2%) articles focused on treatment, 11 (12.2%) on quality of care, 8 (9%) on prevention, 13 (14.4%) on education, 6 (6.6%) on data collection, and 5 (5.5%) on patient monitoring. Overall, 66 (73%) articles reported positive effects, 21 (23%) were neutral and 3 (4%) reported negative results.

CONCLUSIONS

Mobile phone technology is widely reported to be an effective tool for HIV/AIDS and TB long-term care. It can substantially reduce disease burden on health care systems by rendering more efficient prevention, treatment, education, data collection and management support.

User interface design for mobile-based sexual health interventions for young people: design recommendations from a qualitative study on an online Chlamydia clinical care pathway

BACKGROUND

The increasing pervasiveness of mobile technologies has given potential to transform healthcare by facilitating clinical management using software applications. These technologies may provide valuable tools in sexual health care and potentially overcome existing practical and cultural barriers to routine testing for sexually transmitted infections. In order to inform the design of a mobile health application for STIs that supports self-testing and self-management by linking diagnosis with online care pathways, we aimed to identify the dimensions and range of preferences for user interface design features among young people.

METHODS

Nine focus group discussions were conducted (n = 49) with two age-stratified samples (16 to 18 and 19 to 24 year olds) of young people from Further Education colleges and Higher Education establishments. Discussions explored young people's views with regard to: the software interface; the presentation of information; and the ordering of interaction steps. Discussions were audio recorded and transcribed verbatim. Interview transcripts were analysed using thematic analysis.

RESULTS

Four over-arching themes emerged: privacy and security; credibility; user journey support; and the task-technology-context fit. From these themes, 20 user interface design recommendations for mobile health applications are proposed. For participants, although privacy was a major concern, security was not perceived as a major potential barrier as participants were generally unaware of potential security threats and inherently trusted new technology. Customisation also emerged as a key design preference to increase attractiveness and acceptability.

CONCLUSIONS

Considerable effort should be focused on designing healthcare applications from the patient's perspective to maximise acceptability. The design recommendations proposed in this paper provide a valuable point of reference for the health design community to inform development of mobile-based health interventions for the diagnosis and treatment of a number of other conditions for this target group, while stimulating conversation across multidisciplinary communities.

A mixed-methods study on the acceptability of using eHealth for HIV prevention and sexual health care among men who have sex with men in China

Background

Human immunodeficiency virus (HIV) infection disproportionately affects men who have sex with men (MSM). Over half of all HIV-positive MSM in China may not know their HIV status. Mobile phones and Web interventions (eHealth) are underutilized resources that show promise for supporting HIV education, testing, and linkage to care.

Objective

This mixed-methods study among MSM in China assessed technology utilization and eHealth acceptability for sexual health care.

Methods

We conducted in-depth interviews and an online survey. Qualitative analyses informed the development of the Internet survey, which was administered through two popular MSM websites. Bivariate and multivariate analysis assessed characteristics of MSM interested in eHealth for sexual health care.

Results

The qualitative sample included MSM across a range of ages, education, marital status, sexuality, and HIV testing experience. Qualitative findings included the importance of the Internet as the primary source of information about sexual health, HIV and other sexually transmitted diseases (STDs), use of the Internet to enable HIV testing opportunities by facilitating connections with both the gay community and health care providers, and mixed perceptions regarding the confidentiality of eHealth tools for sexual health. Among the Internet sample (N=1342), the average age was 30.6 years old, 82.81% (1098/1342) were single, and 53.42% (711/1331) had completed college. In the past 3 months, 38.66% (382/988) had condomless sex and 60.53% (805/1330) self-reported having ever tested for HIV. The majority of men owned computers (94.14%, 1220/1296) and mobile phones (92.32%, 1239/1342), which many had used to search for HIV/STD information and testing sites. In multivariate analysis, interest in using computers or mobile phones to support their sexual health care was associated with being a student, prior use of computers or mobile phones to search for general health information, prior use of computers or mobile phones to search for HIV/STD information, and confidentiality concerns.

Conclusions

MSM in this sample had high utilization of technology and interest in eHealth despite confidentiality concerns. Future eHealth interventions can thoughtfully and creatively address these concerns as a priority for successful implementation.

Preferences for a Mobile HIV Prevention App for Men Who Have Sex With Men

Background

The Centers for Disease Control and Prevention recommends that sexually active men who have sex with men (MSM) in the United States test for human immunodeficiency virus (HIV) at least three times per year, but actual testing frequency is much less frequent. Though mHealth is a popular vehicle for delivering HIV interventions, there are currently no mobile phone apps that target MSM with the specific aim of building an HIV testing plan, and none that focuses on developing a comprehensive prevention plan and link MSM to additional HIV prevention and treatment resources. Previous research has suggested a need for more iterative feedback from the target population to ensure use of these interventions.

Objective

The purpose of this study is to understand MSM’s preferences for functionality, format, and design of a mobile phone-based HIV prevention app and to examine MSM’s willingness to use an app for HIV prevention.

Methods

We conducted focus group discussions with 38 gay and bisexual men, with two in-person groups in Atlanta, two in Seattle, and one online focus group discussion with gay and bisexual men in rural US regions. These discussions addressed MSM’s general preferences for apps, HIV testing barriers and facilitators for MSM, and ways that an HIV prevention app could address these barriers and facilitators to increase the frequency of HIV testing and prevention among MSM. During focus group discussions, participants were shown screenshots and provided feedback on potential app functions.

Results

Participants provided preferences on functionality of the app, including the type and delivery of educational content, the value of interactive engagement, and the importance of social networking as an app component. Participants also discussed preferences on how the language should be framed for the delivery of information, identifying that an app needs to be simultaneously fun and professional. Privacy and altruistic motivation were considered to be important factors in men’s willingness to use a mobile HIV prevention app. Finally, men described the potential impact that a mobile HIV prevention app could have, identifying individual, interpersonal, and community-based benefits.

Conclusions

In summary, participants described a comprehensive app that should incorporate innovative ideas to educate and engage men so that they would be motivated to use the app. In order for an app to be useful, it needs to feel safe and trustworthy, which is essential when considering the app’s language and privacy. Participants provided a range of preferences for using an HIV prevention app, including what they felt MSM need with regards to HIV prevention and what they want in order to engage with an app. Making an HIV prevention app enjoyable and usable for MSM is a difficult challenge. However, the usability of the app is vital because no matter how great the intervention, if MSM do not use the app, then it will not be useful.

Putting prevention in their pockets: developing mobile phone-based HIV interventions for black men who have sex with men

Young black men who have sex with men (MSM) bear a disproportionate burden of HIV. Rapid expansion of mobile technologies, including smartphone applications (apps), provides a unique opportunity for outreach and tailored health messaging. We collected electronic daily journals and conducted surveys and focus groups with 22 black MSM (age 18-30) at three sites in North Carolina to inform the development of a mobile phone-based intervention. Qualitative data was analyzed thematically using NVivo. Half of the sample earned under $11,000 annually. All participants owned smartphones and had unlimited texting and many had unlimited data plans. Phones were integral to participants' lives and were a primary means of Internet access. Communication was primarily through text messaging and Internet (on-line chatting, social networking sites) rather than calls. Apps were used daily for entertainment, information, productivity, and social networking. Half of participants used their phones to find sex partners; over half used phones to find health information. For an HIV-related app, participants requested user-friendly content about test site locators, sexually transmitted diseases, symptom evaluation, drug and alcohol risk, safe sex, sexuality and relationships, gay-friendly health providers, and connection to other gay/HIV-positive men. For young black MSM in this qualitative study, mobile technologies were a widely used, acceptable means for HIV intervention. Future research is needed to measure patterns and preferences of mobile technology use among broader samples.

Mobile phone applications for the care and prevention of HIV and other sexually transmitted diseases: a review

BACKGROUND

Mobile phone applications (apps) provide a new platform for delivering tailored human immunodeficiency virus (HIV) and sexually transmitted disease (STD) prevention and care.

OBJECTIVE

To identify and evaluate currently available mobile phone apps related to the prevention and care of HIV and other STDs.

METHODS

We searched the Apple iTunes and Android Google Play stores for HIV/STD-related apps, excluding apps that exclusively targeted industry, providers, and researchers. Each eligible app was downloaded, tested, and assessed for user ratings and functionality as well as 6 broad content areas of HIV prevention and care: HIV/STD disease knowledge, risk reduction/safer sex, condom promotion, HIV/STD testing information, resources for HIV-positive persons, and focus on key populations.

RESULTS

Search queries up to May 2012 identified 1937 apps. Of these, 55 unique apps met the inclusion criteria (12 for Android, 29 for iPhone, and 14 for both platforms). Among these apps, 71% provided disease information about HIV/STDs, 36% provided HIV/STD testing information or resources, 29% included information about condom use or assistance locating condoms, and 24% promoted safer sex. Only 6 apps (11%) covered all 4 of these prevention areas. Eight apps (15%) provided tools or resources specifically for HIV/STD positive persons. Ten apps included information for a range of sexual orientations, 9 apps appeared to be designed for racially/ethnically diverse audiences, and 15 apps featured interactive components. Apps were infrequently downloaded (median 100-500 downloads) and not highly rated (average customer rating 3.7 out of 5 stars).

CONCLUSIONS

Most available HIV/STD apps have failed to attract user attention and positive reviews. Public health practitioners should work with app developers to incorporate elements of evidence-based interventions for risk reduction and improve app inclusiveness and interactivity.