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Mureithi M, Ng’aari L, Wasunna B, Kiruthu-Kamamia C, Sande O, Chiwaya GD, Huwa J, Tweya H, Jafa K, Feldacker C. Centering healthcare workers in digital health design: Usability and acceptability of two-way texting to improve retention in antiretroviral therapy in a public HIV clinic in Lilongwe, Malawi. PLOS DIGITAL HEALTH 2024; 3:e0000480. [PMID: 38568904 PMCID: PMC10990210 DOI: 10.1371/journal.pdig.0000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/28/2024] [Indexed: 04/05/2024]
Abstract
New initiates on antiretroviral therapy (ART) are at high risk of treatment discontinuation, putting their health at risk. In low- and middle-income countries, like Malawi, appropriate digital health applications (apps) must fit into local clinic, connectivity and resource constraints. We describe the human centered design (HCD) and development process of an open-source, hybrid, two-way texting (2wT) system to improve ART retention. We detail the critical role of diverse healthcare workers (HCWs) in the HCD process to inform app usability, create buy-in, and ensure appropriate optimization for the local context. We optimized 2wT usability and acceptability over three HCD phases: 1) informal feedback sessions with diverse 2wT stakeholders, 2) a small pilot, and 3) key informant interviews. Phase one included four sessions with diverse HCWs, including "expert ART clients", clinical, technical, supervisory, and evaluation teams to inform 2wT design. In phase 2, a small pilot with 50 participating ART clients aimed to inform implementation improvement. Phase three included interviews with ten HCWs to deepen understanding of 2wT acceptability and usability, documenting strengths and weaknesses to inform optimization. Multi-phase feedback sessions with HCWs helped refine 2wT language and message timing for both weekly and tailored client-specific visit reminders. The pilot led to improvements in educational materials to guide client responses and ease interaction with HCWs. In interviews, the HCWs appreciated the HCD co-creation process, suggested ways to increase access for low-literacy clients or those without consistent phone access, and felt integrating 2wT with other eHealth platforms would improve scalability. Inclusion of HCWs across phases of HCD design, adaption, and optimization increased 2wT usability and acceptability among HCWs in this setting. Engaging HCWs into 2wT co-ownership from inception appears successful in co-creation of an app that will meet HCW needs, and therefore, enhance support for 2wT clients to attend visits and remain in care.
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Affiliation(s)
| | | | | | - Christine Kiruthu-Kamamia
- Lighthouse Trust, Lilongwe, Malawi
- International Training and Education Center for Health, Lilongwe, Malawi
| | | | | | | | - Hannock Tweya
- International Training and Education Center for Health, Lilongwe, Malawi
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Krishna Jafa
- Medic, Seattle, Washington, United States of America
| | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, Washington, United States of America
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Su Y, Mukora R, Ndebele F, Pienaar J, Khumalo C, Xu X, Tweya H, Sardini M, Day S, Sherr K, Setswe G, Feldacker C. Cost savings in male circumcision post-operative care using two-way text-based follow-up in rural and urban South Africa. PLoS One 2023; 18:e0294449. [PMID: 37972009 PMCID: PMC10653449 DOI: 10.1371/journal.pone.0294449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023] Open
Abstract
INTRODUCTION Voluntary medical male circumcision (VMMC) clients are required to attend multiple post-operative follow-up visits in South Africa. However, with demonstrated VMMC safety, stretched clinic staff in SA may conduct more than 400,000 unnecessary reviews for males without complications, annually. Embedded into a randomized controlled trial (RCT) to test safety of two-way, text-based (2wT) follow-up as compared to routine in-person visits among adult clients, the objective of this study was to compare 2wT and routine post-VMMC care costs in rural and urban South African settings. METHODS Activity-based costing (ABC) estimated the costs of post-VMMC care, including counselling, follow-ups, and tracing in $US dollars. Transportation for VMMC and follow-up was provided for rural clients in outreach settings but not for urban clients in static sites. Data were collected from National Department of Health VMMC forms, RCT databases, and time-and-motion surveys. Sensitivity analysis presents different follow-up scenarios. We hypothesized that 2wT would save per-client costs overall, with higher savings in rural settings. RESULTS VMMC program costs were estimated from 1,084 RCT clients: 537 in routine care and 547 in 2wT. On average, 2wT saved $3.56 per client as compared to routine care. By location, 2wT saved $7.73 per rural client and increased urban costs by $0.59 per client. 2wT would save $2.16 and $7.02 in follow-up program costs if men attended one or two post-VMMC visits, respectively. CONCLUSION Quality 2wT follow-up care reduces overall post-VMMC care costs by supporting most men to heal at home while triaging clients with potential complications to timely, in-person care. 2wT saves more in rural areas where 2wT offsets transportation costs. Minimal additional 2wT costs in urban areas reflect high care quality and client engagement, a worthy investment for improved VMMC service delivery. 2wT scale-up in South Africa could significantly reduce overall VMMC costs while maintaining service quality.
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Affiliation(s)
- Yanfang Su
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | | | | | - Jacqueline Pienaar
- The Aurum Institute, Johannesburg, South Africa
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
| | | | - Xinpeng Xu
- School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hannock Tweya
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Maria Sardini
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
| | - Sarah Day
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Geoffrey Setswe
- The Aurum Institute, Johannesburg, South Africa
- Department of Health Studies, University of South Africa (UNISA), Pretoria, South Africa
| | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
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Feldacker C, Mugwanya R, Irongo D, Kathumba D, Chiwoko J, Kitsao E, Sippell K, Wasunna B, Jonas K, Samala B, Mwakanema D, Oni F, Jafa K, Tweya H. A Community-Based, Mobile Electronic Medical Record System App for High-Quality, Integrated Antiretroviral Therapy in Lilongwe, Malawi: Design Process and Pilot Implementation. JMIR Form Res 2023; 7:e48671. [PMID: 37948102 PMCID: PMC10674144 DOI: 10.2196/48671] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/05/2023] [Accepted: 10/08/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Differentiated service delivery (DSD) increases antiretroviral therapy (ART) access in sub-Saharan Africa by moving clients out of congested ART clinics to communities for care. However, DSD settings challenge provider adherence to complex, chronic care treatment guidelines and have burdensome systems for client monitoring and evaluation (M&E), reducing data for decision-making. Electronic medical record systems (EMRS) improve client outcomes and reduce M&E workload. Traditional EMRS cannot operate in most DSD settings with unreliable power and poor connectivity. OBJECTIVE This study aims to detail the human-centered design (HCD) process of developing a mobile EMRS for community-based DSD services in Lilongwe, Malawi. METHODS Lighthouse Trust (LT) operates 2 Ministry of Health (MoH) clinics in Lilongwe, Malawi, with a combined total of >35,000 ART clients. LT's real-time, point-of-care EMRS collects complex client M&E data and provides decision-making support, ensuring adherence to integrated HIV and tuberculosis guidelines that optimize client and program outcomes. LT's EMRS scaled to all large MoH ART clinics. LT also implements a nurse-led community-based ART program (NCAP), a DSD model to provide ART and rapid assessment for 2400 stable LT clients in the community. LT, alongside collaborators, from the University of Washington's International Training and Education Center for Health and technology partner, Medic, used the open-source Community Health Toolkit (CHT) and HCD to develop an open-source, offline-first, mobile EMRS-like app, "community-based ART retention and suppression" (CARES). CARES aims to bring EMRS-like provider benefits to NCAP's DSD clients. RESULTS CARES design took approximately 12 months and used an iterative process of highly participatory feedback sessions with provider, data manager, and M&E team inputs to ensure CARES optimization for the NCAP and LT settings. The CARES mobile EMRS prototype supports NCAP providers with embedded prompts and alerts to ensure adherence to integrated MoH ART guidelines, aiming to improve the quality of client care. CARES facilitates improved data quality and flow for NCAP M&E, aiming to reduce data gaps between community and clinic settings. The CARES pilot demonstrates the potential of a mobile, point-of-care EMRS-like app that could benefit NCAP clients, providers, and program teams with integrated client care and complete M&E data for decision-making. CARES challenges include app speed, search features to align longitudinal records, and CARES to EMRS integration that supports timely care alerts. CONCLUSIONS Leveraging the CHT and HCD processes facilitated the design of a locally specified and optimized mobile app with the promise to bring EMRS-like benefits to DSD settings. Moving from the CARES prototype to routine NCAP implementation should result in improved client care and strengthened M&E while reducing workload. Our transparent and descriptive process shares the progress and pitfalls of the CARES design and development, helping others in this digital innovation area to learn from our experiences at this stage.
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Affiliation(s)
- Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States
- International Training and Education Center for Health, Seattle, WA, United States
| | | | | | | | | | | | | | | | | | | | - Daniel Mwakanema
- International Training and Education Center for Health, Lilongwe, Malawi
| | | | | | - Hannock Tweya
- Department of Global Health, University of Washington, Seattle, WA, United States
- International Training and Education Center for Health, Lilongwe, Malawi
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Su Y, Mukora R, Ndebele F, Pienaar J, Khumalo C, Xu X, Tweya H, Sardini M, Day S, Sherr K, Setswe G, Feldacker C. Cost savings in male circumcision post-operative care using two-way text-based follow-up in rural and urban South Africa. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.08.23284877. [PMID: 36798405 PMCID: PMC9934777 DOI: 10.1101/2023.02.08.23284877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Introduction Voluntary medical male circumcision (VMMC) clients are required to attend multiple post-operative follow-up visits in South Africa. However, with demonstrated VMMC safety, stretched clinic staff in SA may conduct more than 400,000 unnecessary reviews for males without complications, annually. Embedded into a randomized controlled trial (RCT) to test safety of two-way, text-based (2wT) follow-up as compared to routine in-person visits among adult clients, the objective of this study was to compare 2wT and routine post-VMMC care costs in rural and urban South African settings. Methods Activity-based costing (ABC) estimated the costs of post-VMMC care, including counselling, follow-ups, and tracing in $US dollars. Transportation for VMMC and follow-up was provided for rural clients in outreach settings but not for urban clients in static sites. Data were collected from National Department of Health VMMC forms, RCT databases, and time-and-motion surveys. Sensitivity analysis presents different follow-up scenarios. We hypothesized that 2wT would save per-client costs overall, with higher savings in rural settings. Results VMMC program costs were estimated from 1,084 RCT clients: 537 in routine care and 547 in 2wT. On average, 2wT saved $3.56 per client as compared to routine care. By location, 2wT saved $7.73 per rural client and increased urban costs by $0.59 per client. 2wT would save $2.16 and $7.02 in follow-up program costs if men attended one or two post-VMMC visits, respectively. Conclusion Quality 2wT follow-up care reduces overall post-VMMC care costs by supporting most men to heal at home while triaging clients with potential complications to timely, in-person care. 2wT saves more in rural areas where 2wT offsets transportation costs. Minimal additional 2wT costs in urban areas reflect high care quality and client engagement, a worthy investment for improved VMMC service delivery. 2wT scale-up in South Africa could significantly reduce overall VMMC costs while maintaining service quality.
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Affiliation(s)
- Yanfang Su
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | | | - Jacqueline Pienaar
- The Aurum Institute, Johannesburg, South Africa
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
| | | | - Xinpeng Xu
- School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hannock Tweya
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
| | - Maria Sardini
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
| | - Sarah Day
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Geoffrey Setswe
- The Aurum Institute, Johannesburg, South Africa
- Department of Health Studies, University of South Africa (UNISA), Pretoria, South Africa
| | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
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Huwa J, Tweya H, Mureithi M, Kiruthu-Kamamia C, Oni F, Chintedza J, Chiwaya G, Waweru E, Kudzala A, Wasunna B, Ndhlovu D, Bisani P, Feldacker C. "It reminds me and motivates me": Human-centered design and implementation of an interactive, SMS-based digital intervention to improve early retention on antiretroviral therapy: Usability and acceptability among new initiates in a high-volume, public clinic in Malawi. PLoS One 2023; 18:e0278806. [PMID: 37471383 PMCID: PMC10358959 DOI: 10.1371/journal.pone.0278806] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/14/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Early retention of people living with HIV (PLHIV) in antiretroviral therapy (ART) programs is critical to improve individual clinical outcomes and viral load suppression. Although many mobile health (mHealth) interventions aim to improve retention in care, there is still lack of evidence on mHealth success or failure, including from patient's perspectives. We describe the human-centered design (HCD) process and assess patient usability and acceptability of a two-way texting (2wT) intervention to improve early retention among new ART initiates at Lighthouse Trust clinic in Lilongwe, Malawi. METHODS An iterative HCD approach focused on patient and provider users' needs, incorporating feedback from multidisciplinary teams to adapt 2wT for the local, public clinic context. We present mixed-methods usability and acceptability results from 100 participants, 50 at 3-months and 50 at 6-months, post 2wT enrollment, and observations of these same patients completing core tasks of the 2wT system. RESULTS Among the 100 usability respondents, 95% were satisfied with visit reminders, and 88% would recommend reminders and motivational messages to friends; however, 17% were worried about confidentiality. In observation of participant task completion, 94% were able to successfully confirm visit attendance and 73% could request appointment date change. More participants in 4-6 months group completed tasks correctly compared to 1-3 months group, although not significantly different (78% vs. 66%, p = 0.181). Qualitative results were overwhelmingly positive, but patients did note confusion with transfer reporting and concern that 2wT would not reach patients without mobile phones or with lower literacy. CONCLUSION The 2wT app for early ART retention appears highly usable and acceptable, hopefully creating a solid foundation for lifelong engagement in care. The HCD approach put the local team central in this process, ensuring that both patients' and Lighthouse's priorities, policies, and practices were forefront in 2wT optimization, raising the likelihood of 2wT success in other routine program contexts.
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Affiliation(s)
| | - Hannock Tweya
- International Training and Education Center for Health (I-TECH), Lilongwe, Malawi
| | | | | | | | | | | | | | | | | | | | | | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
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Feldacker C, Pienaar J, Wasunna B, Ndebele F, Khumalo C, Day S, Tweya H, Oni F, Sardini M, Adhikary B, Waweru E, Wafula MB, Dixon A, Jafa K, Su Y, Sherr K, Setswe G. Expanding the Evidence on the Safety and Efficiency of 2-Way Text Messaging-Based Telehealth for Voluntary Medical Male Circumcision Follow-up Compared With In-Person Reviews: Randomized Controlled Trial in Rural and Urban South Africa. J Med Internet Res 2023; 25:e42111. [PMID: 37159245 DOI: 10.2196/42111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/22/2022] [Accepted: 02/24/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND There is a dearth of high-quality evidence from digital health interventions in routine program settings in low- and middle-income countries. We previously conducted a randomized controlled trial (RCT) in Zimbabwe, demonstrating that 2-way texting (2wT) was safe and effective for follow-up after adult voluntary medical male circumcision (VMMC). OBJECTIVE To demonstrate the replicability of 2wT, we conducted a larger RCT in both urban and rural VMMC settings in South Africa to determine whether 2wT improves adverse event (AE) ascertainment and, therefore, the quality of follow-up after VMMC while reducing health care workers' workload. METHODS A prospective, unblinded, noninferiority RCT was conducted among adult participants who underwent VMMC with cell phones randomized in a 1:1 ratio between 2wT and control (routine care) in North West and Gauteng provinces. The 2wT participants responded to a daily SMS text message with in-person follow-up only if desired or an AE was suspected. The control group was requested to make in-person visits on postoperative days 2 and 7 as per national VMMC guidelines. All participants were asked to return on postoperative day 14 for study-specific review. Safety (cumulative AEs ≤day 14 visit) and workload (number of in-person follow-up visits) were compared. Differences in cumulative AEs were calculated between groups. Noninferiority was prespecified with a margin of -0.25%. The Manning score method was used to calculate 95% CIs. RESULTS The study was conducted between June 7, 2021, and February 21, 2022. In total, 1084 men were enrolled (2wT: n=547, 50.5%, control: n=537, 49.5%), with near-equal proportions of rural and urban participants. Cumulative AEs were identified in 2.3% (95% CI 1.3-4.1) of 2wT participants and 1.0% (95% CI 0.4-2.3) of control participants, demonstrating noninferiority (1-sided 95% CI -0.09 to ∞). Among the 2wT participants, 11 AEs (9 moderate and 2 severe) were identified, compared with 5 AEs (all moderate) among the control participants-a nonsignificant difference in AE rates (P=.13). The 2wT participants attended 0.22 visits, and the control participants attended 1.34 visits-a significant reduction in follow-up visit workload (P<.001). The 2wT approach reduced unnecessary postoperative visits by 84.8%. Daily response rates ranged from 86% on day 3 to 74% on day 13. Among the 2wT participants, 94% (514/547) responded to ≥1 daily SMS text messages over 13 days. CONCLUSIONS Across rural and urban contexts in South Africa, 2wT was noninferior to routine in-person visits for AE ascertainment, demonstrating 2wT safety. The 2wT approach also significantly reduced the follow-up visit workload, improving efficiency. These results strongly suggest that 2wT provides quality VMMC follow-up and should be adopted at scale. Adaptation of the 2wT telehealth approach to other acute follow-up care contexts could extend these gains beyond VMMC. TRIAL REGISTRATION ClinicalTrials.gov NCT04327271; https://www.clinicaltrials.gov/ct2/show/NCT04327271.
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Affiliation(s)
- Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, United States
| | | | | | | | | | - Sarah Day
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Hannock Tweya
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | | | | | | | | | | | | | - Yanfang Su
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Geoffrey Setswe
- Aurum Institute, Johannesburg, South Africa
- Department of Health Studies, University of South Africa (UNISA), Pretoria, South Africa
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Day S, Ncube V, Maja L, Wasunna B, Pienaar J, Setswe G, Waweru E, Feldacker C. Centering Frontline Health Care Workers in Digital Innovation Design to Inform the Optimization of an App for Improved Male Circumcision Follow-up in South Africa: Qualitative Usability Study. JMIR Form Res 2023; 7:e44122. [PMID: 36947127 PMCID: PMC10131628 DOI: 10.2196/44122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/24/2023] [Accepted: 02/05/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Voluntary medical male circumcision (VMMC) is a safe and effective HIV prevention strategy. However, adherence to recommended in-person, postoperative follow-up is inefficient for procedures with few adverse events. Two-way texting (2wT)-based follow-up appears to be a safe and an efficient alternative to scheduled clinic visits for low-risk patients who underwent VMMC. To ensure that 2wT responds to the needs of health care workers (HCWs) and patients, HCWs were closely involved in app design using a human-centered design (HCD) approach. OBJECTIVE Embedded within an ongoing randomized controlled trial of 2wT in South Africa and complementary HCD processes of 2wT app optimization, this qualitative study aimed to use key informant interviews (KIIs) to explore the thoughts, suggestions, and opinions on and perceptions of 2wT's usability and acceptability among HCWs involved in 2wT implementation in both urban and rural South Africa. METHODS A total of 7 HCWs using 2wT in Gauteng and the North West province participated in KIIs regarding the usability and acceptability of 2wT. HCWs were asked for their opinions on 2wT as a viable, useful, appropriate, and accessible method of postoperative VMMC care. They were also asked about 2wT-related working, exploring areas where 2wT could add to or reduce their daily tasks. The KII data were explored, coded, and analyzed by 3 qualitative researchers using thematic content analysis and the ATLAS.ti (ATLAS.ti Scientific Software Development GmbH) software. RESULTS Most HCWs felt confident, comfortable, satisfied, and well supported using a 2wT-based follow-up as an alternative to in-person clinical reviews. They felt that 2wT was easy to use and required little technical support after initial mentoring on how to use the 2wT system. Few noted safety concerns, as men can receive clinical guidance, reassurance, and referral via 2wT. Although fewer in-person visits reduced the in-person review workload and eased clinical flow, HCWs noted the added burden of having to interact with clients via SMS text messages on evenings or weekends. HCWs reinforced the need for enhanced postoperative counseling to ensure that 2wT patients could recognize and understood how to respond to early signs of complications. HCWs suggested a rotation to spread the evening and weekend workload and ensure swift patient responses. CONCLUSIONS In this formative qualitative study focused on HCWs, 2wT was a highly usable alternative to in-person postoperative reviews for patients who underwent VMMC in South Africa. The HCD processes likely improved the usability and acceptability of 2wT for HCWs. HCWs supported the scale-up of 2wT given the distance from the clinic to the men's homes and the potential for reducing workload. To ensure success, providers urged sensitizing patients to the fact that 2wT augments, but does not replace, the existing after-hours and emergency care services.
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Affiliation(s)
- Sarah Day
- Division of Social and Behavioural Sciences, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- The Centre for HIV-AIDS Prevention Studies, Johannesburg, South Africa
| | | | | | | | - Jacqueline Pienaar
- The Centre for HIV-AIDS Prevention Studies, Johannesburg, South Africa
- The Aurum Institute, Johannesburg, South Africa
| | | | | | - Caryl Feldacker
- International Training and Education Center for Health, University of Washington, Seattle, WA, United States
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Pienaar J, Day S, Setswe G, Wasunna B, Ncube V, Ndebele F, Oni F, Waweru E, Khumalo C, Tweya H, Sherr K, Su Y, Feldacker C. 'I understood the texting process well'. Participant perspectives on usability and acceptability of SMS-based telehealth follow-up after voluntary medical male circumcision in South Africa. Digit Health 2023; 9:20552076231194924. [PMID: 37654716 PMCID: PMC10467206 DOI: 10.1177/20552076231194924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 07/28/2023] [Indexed: 09/02/2023] Open
Abstract
Background Voluntary medical male circumcision (MC) is a biomedical HIV prevention method that requires post-operative follow-up for healing confirmation. Recent research found that a two-way texting (2wT) app providing SMS-based telehealth for MC patients was safe and reduced provider workload. We evaluated 2wT usability among MC clients in South Africa assigned the 2wT intervention within a larger randomized controlled trial (RCT) of 2wT safety and workload. Methods This quantitative usability study is within an RCT where 547 men used 2wT to interact with an MC provider via SMS. The sub-study involved the first 100 men assigned to 2wT who completed a usability survey 14 days after surgery. Acceptability was assessed through 2wT response rates of the 547 men. Regression models analyzed associations between age, wage, location, potential adverse events (AEs), and 2wT responses. Results Men assigned to 2wT found it safe, comfortable, and convenient, reporting time and cost savings. High response rates (88%) to daily messages indicated acceptability. Age, wage, and location didn't affect text responses or potential AEs. Conclusion 2wT for post-MC follow-up was highly usable and acceptable, suggesting its viability as an alternative to in-person visits. It enhanced confidence in wound self-management. This SMS-based telehealth can enhance MC care quality and be adapted to similar contexts for independent healing support, particularly for men.
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Affiliation(s)
- Jacqueline Pienaar
- Implementation Science Division, The Aurum Institute, Johannesburg, South Africa
| | - Sarah Day
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Geoffrey Setswe
- Implementation Science Division, The Aurum Institute, Johannesburg, South Africa
- Department of Health Studies, University of South Africa (UNISA), Pretoria, South Africa
| | | | - Vuyolwethu Ncube
- Implementation Science Division, The Aurum Institute, Johannesburg, South Africa
| | - Felex Ndebele
- Implementation Science Division, The Aurum Institute, Johannesburg, South Africa
| | | | | | - Calsile Khumalo
- Implementation Science Division, The Aurum Institute, Johannesburg, South Africa
| | - Hannock Tweya
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Yanfang Su
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Caryl Feldacker
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
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Transitioning a digital health innovation from research to routine practice: Two-way texting for male circumcision follow-up in Zimbabwe. PLOS DIGITAL HEALTH 2022; 1:e0000066. [PMID: 36812548 PMCID: PMC9931231 DOI: 10.1371/journal.pdig.0000066] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/16/2022] [Indexed: 11/19/2022]
Abstract
Adult medical male circumcision (MC) is safe: global notifiable adverse event (AE) rates average below 2.0%. With Zimbabwe's shortage of health care workers (HCWs) compounded by COVID-19 constraints, two-way text-based (2wT) MC follow-up may be advantageous over routinely scheduled in-person reviews. A 2019 randomized control trial (RCT) found 2wT to be safe and efficient for MC follow-up. As few digital health interventions successfully transition from RCT to scale, we detail the 2wT scale-up approach from RCT to routine MC practice comparing MC safety and efficiency outcomes. After the RCT, 2wT transitioned from a site-based (centralized) system to hub-and-spoke model for scale-up where one nurse triaged all 2wT patients, referring patients in need to their local clinic. No post-operative visits were required with 2wT. Routine patients were expected to attend at least one post-operative review. We compare 1) AEs and in-person visits between 2wT men from RCT and routine MC service delivery; and 2) 2wT-based and routine follow-up among adults during the 2wT scale-up period, January to October 2021. During scale-up period, 5084 of 17417 adult MC patients (29%) opted into 2wT. Of the 5084, 0.08% (95% CI: 0.03, 2.0) had an AE and 71.0% (95% CI: 69.7, 72.2) responded to ≥1 daily SMS, a significant decrease from the 1.9% AE rate (95% CI: 0.7, 3.6; p<0.001) and 92.5% response rate (95% CI: 89.0, 94.6; p<0.001) from 2wT RCT men. During scale-up, AE rates did not differ between routine (0.03%; 95% CI: 0.02, 0.08) and 2wT (p = 0.248) groups. Of 5084 2wT men, 630 (12.4%) received telehealth reassurance, wound care reminders, and hygiene advice via 2wT; 64 (19.7%) were referred for care of which 50% had visits. Similar to RCT outcomes, routine 2wT was safe and provided clear efficiency advantages over in-person follow-up. 2wT reduced unnecessary patient-provider contact for COVID-19 infection prevention. Rural network coverage, provider hesitancy, and the slow pace of MC guideline changes slowed 2wT expansion. However, immediate 2wT benefits for MC programs and potential benefits of 2wT-based telehealth for other health contexts outweigh limitations.
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Telemedicine in Surgical Care in Low- and Middle-Income Countries: A Scoping Review. World J Surg 2022; 46:1855-1869. [PMID: 35428920 PMCID: PMC9012517 DOI: 10.1007/s00268-022-06549-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 12/11/2022]
Abstract
Background Access to timely and quality surgical care is limited in low- and middle-income countries (LMICs). Telemedicine, defined as the remote provision of health care using information, communication and telecommunication platforms have the potential to address some of the barriers to surgical care. However, synthesis of evidence on telemedicine use in surgical care in LMICs is lacking. Aim To describe the current state of evidence on the use and distribution of telemedicine for surgical care in LMICs. Methods This was a scoping review of published and relevant grey literature on telemedicine use for surgical care in LMICs, following the PRISMA extension for scoping reviews guideline. PubMed-Medline, Web of Science, Scopus and African Journals Online databases were searched using a comprehensive search strategy from 1 January 2010 to 28 February 2021. Results A total of 178 articles from 53 (38.7%) LMICs across 11 surgical specialties were included. The number of published articles increased from 2 in 2010 to 44 in 2020. The highest number of studies was from the World Health Organization Western Pacific region (n = 73; 41.0%) and of these, most were from China (n = 69; 94.5%). The most common telemedicine platforms used were telephone call (n = 71, 39.9%), video chat (n = 42, 23.6%) and WhatsApp/WeChat (n = 31, 17.4%). Telemedicine was mostly used for post-operative follow-up (n = 71, 39.9%), patient education (n = 32, 18.0%), provider training (n = 28, 15.7%) and provider-provider consultation (n = 16, 9.0%). Less than a third (n = 51, 29.1%) of the studies used a randomised controlled trial design, and only 23 (12.9%) reported effects on clinical outcomes. Conclusion Telemedicine use for surgical care is emerging in LMICs, especially for post-operative visits. Basic platforms such as telephone calls and 2-way texting were successfully used for post-operative follow-up and education. In addition, file sharing and video chatting options were added when a physical assessment was required. Telephone calls and 2-way texting platforms should be leveraged to reduce loss to follow-up of surgical patients in LMICs and their use for pre-operative visits should be further explored. Despite these telemedicine potentials, there remains an uneven adoption across several LMICs. Also, up to two-thirds of the studies were of low-to-moderate quality with only a few focusing on clinical effectiveness. There is a need to further adopt, develop, and validate telemedicine use for surgical care in LMICs, particularly its impact on clinical outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-022-06549-2.
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Goehner D, Kandregula S, Birk H, Carroll CP, Guthikonda B, Kosty JA. Improving patient care in neurosurgery through postoperative telephone calls: a systematic review and lessons from all surgical specialties. Neurosurg Focus 2021; 51:E5. [PMID: 34724638 DOI: 10.3171/2021.8.focus21410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/25/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postoperative telephone calls are a simple intervention that can be used to improve communication with patients, potentially affecting patient safety and satisfaction. Few studies in the neurosurgical literature have examined the effect of a postoperative telephone call on patient outcomes, although several exist across all surgical specialties. The authors performed a systematic review and analyzed studies published since 2000 to assess the effect of a postoperative telephone call or text message on patient safety and satisfaction across all surgical specialties. METHODS A search of PubMed-indexed articles was performed on June 12, 2021, and was narrowed by the inclusion criteria of studies from surgical specialties with > 50 adult patients published after 1999, in which a postoperative telephone call was made and its effects on safety and satisfaction were assessed. Exclusion criteria included dental, medical, and pediatric specialties; systematic reviews; meta-analyses; and non-English-language articles. Dual review was utilized. RESULTS Overall, 24 articles met inclusion criteria. The majority reported an increase in patient satisfaction scores after a postoperative telephone call was implemented, and half of the studies demonstrated an improvement in safety or outcomes. CONCLUSIONS Taken together, these studies demonstrate that implementation of a postoperative telephone call in a neurosurgical practice is a feasible way to enhance patient care. The major limitations of this study were the heterogeneous group of studies and the limited neurosurgery-specific studies.
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Affiliation(s)
- Dylan Goehner
- 1University of Massachusetts Medical School, Department of General Surgery, Worcester, Massachusetts
| | - Sandeep Kandregula
- 2Louisiana State University Health Shreveport School of Medicine, Department of Neurosurgery, Shreveport, Louisiana
| | - Harjus Birk
- 2Louisiana State University Health Shreveport School of Medicine, Department of Neurosurgery, Shreveport, Louisiana
| | - Christopher P Carroll
- 3Department of Brain & Spine Surgery, Naval Medical Center, Portsmouth, Virginia; and.,4Department of Surgery, Division of Neurosurgery, Uniformed Services University, Bethesda, Maryland
| | - Bharat Guthikonda
- 2Louisiana State University Health Shreveport School of Medicine, Department of Neurosurgery, Shreveport, Louisiana
| | - Jennifer A Kosty
- 2Louisiana State University Health Shreveport School of Medicine, Department of Neurosurgery, Shreveport, Louisiana
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O’Bryan G, Feldacker C, Ensminger A, Nghatanga M, Brandt L, Shepard M, Billah I, Aupokolo M, Mengistu AT, Forster N, Zemburuka B, Sithole E, Mutandi G, Barnhart S, O’Malley G. Adverse event profile and associated factors following surgical voluntary medical male circumcision in two regions of Namibia, 2015-2018. PLoS One 2021; 16:e0258611. [PMID: 34669709 PMCID: PMC8528325 DOI: 10.1371/journal.pone.0258611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/30/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Monitoring clinical safety of voluntary medical male circumcision (VMMC) is critical to minimize risk as VMMC programs for HIV prevention are scaled. This cross-sectional analysis describes the adverse event (AE) profile of a large-scale, routine VMMC program and identifies factors associated with the development, severity, and timing of AEs to provide recommendations for program quality improvement. Materials and methods From 2015–2018 there were 28,990 circumcisions performed in International Training and Education Center for Health (I-TECH) supported regions of Namibia in collaboration with the Ministry of Health and Social Services. Two routine follow-up visits after VMMC were scheduled to identify clients with AEs. Summary statistics were used to describe characteristics of all VMMC clients and the subset who experienced an AE. We used chi-square tests to evaluate associations between AE timing, patient age, and other patient and AE characteristics. We used a logistic regression model to explore associations between patient characteristics and AE severity. Results Of the 498 clients with AEs (AE rate of 1.7%), 40 (8%) occurred ≤2 days, 262 (53%) occurred 3–7 days, 161 (32%) between day 8 and 14, and 35 (7%) were ≥15 days post-VMMC. Early AEs (on or before day 2) tended to be severe and categorized as bleeding, while infections were the most common AEs occurring later (p<0.001). Younger clients (aged 10–14 years) experienced more infections, whereas older clients experienced more bleeding (p<0.001). Conclusions Almost 40% of AEs occurred after the second follow-up visit, of which 179 (91%) were infections. Improvements in pre-surgical and post-surgical counselling and post-operative educational materials encouraging clients to seek care at any time, adoption of alternative follow-up methods, and the addition of a third follow-up visit may improve outcomes for patients. Enhancing post-surgical counselling and emphasizing wound care for younger VMMC clients and their caregivers could help mitigate elevated risk of infection.
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Affiliation(s)
- Gillian O’Bryan
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- * E-mail:
| | - Caryl Feldacker
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Alison Ensminger
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Magdaleena Nghatanga
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Windhoek, Namibia
| | - Laura Brandt
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Windhoek, Namibia
| | - Mark Shepard
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Windhoek, Namibia
| | - Idel Billah
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Windhoek, Namibia
| | - Mekondjo Aupokolo
- Directorate of Special Programs-Ministry of Health and Social Services, Windhoek, Namibia
| | | | - Norbert Forster
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Windhoek, Namibia
| | - Brigitte Zemburuka
- Centers for Disease Control and Prevention (CDC/DDPHSIS/CGH/DGHT), Windhoek, Namibia
| | - Edwin Sithole
- Centers for Disease Control and Prevention (CDC/DDPHSIS/CGH/DGHT), Windhoek, Namibia
| | - Gram Mutandi
- Centers for Disease Control and Prevention (CDC/DDPHSIS/CGH/DGHT), Windhoek, Namibia
| | - Scott Barnhart
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Gabrielle O’Malley
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
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Victor O, Phiona M, Vernon M, Thoko M, Paidamoyo G, Farai G, Joseph H, Munyaradzi T, Olban R, Pesanai C, Mufuta T, Vuyelwa SC, Sinokuthemba X, Batsirai MC, Marrianne H, Scott B, Feldacker C. Adverse Event Trends Within a Large-Scale, Routine, Voluntary Medical Male Circumcision Program in Zimbabwe, 2014-2019. J Acquir Immune Defic Syndr 2021; 88:173-180. [PMID: 34173789 PMCID: PMC8434989 DOI: 10.1097/qai.0000000000002751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 05/20/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Between 2008 and 2020, over 22.6 million male circumcisions (MCs) were performed among men ≥10 years in 15 priority countries of East and Southern Africa. Few studies from routine MC programs operating at scale describe trends of adverse events (AEs) or AE rates over time. SETTING Routine program data from a large MC program in Zimbabwe. METHODS χ2 compared characteristics of patients with AEs. Univariable and multivariable logistic models examined factors associated with AE severity. Cochran-Armitage trend tests compared AE rate trends by year (2014-2019), age, and MC method (2017-2019). RESULTS From 2014 to 2019, 469,000 men were circumcised; of the total men circumcised, 38%, 27%, and 35% were conducted among individuals aged 10-14; 15-19; and ≥20 years, respectively. Most MCs (95%) used surgical (dorsal slit or forceps-guided) methods; 5% were device based (PrePex). AEs were reported among 632 (0.13%) MCs; 0.05% were severe. From 2015 to 2019, overall AE rates declined from 34/10,000 to 5/10,000 (P-value <0.001). Severe AE rates also decreased over this period from 12/10,000 to 2/10,000 (P-value <0.001). AE rates among younger clients, aged 10-14 (18/10,000) were higher than among older age men (9/10,000) aged ≥20 years (P < 0.001); however, there was no significant association between age and AE severity. CONCLUSION AE rates each year and over time were lower than the World Health Organization acceptable maximum (2% AEs). ZAZIC quality assurance activities ensured guideline adherence, mentored clinicians to MC competency, promoted quality client education and counseling, and improved AE reporting over time. Decreases in AE rates are likely attributed to safety gains and increasing provider experience.
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Affiliation(s)
- Omollo Victor
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Marongwe Phiona
- Zimbabwe Technical Training and Education Center for Health (ZIMTTECH), Harare, Zimbabwe
| | - Murenje Vernon
- Zimbabwe Technical Training and Education Center for Health (ZIMTTECH), Harare, Zimbabwe
| | - Madoda Thoko
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Gonouya Paidamoyo
- Zimbabwe Technical Training and Education Center for Health (ZIMTTECH), Harare, Zimbabwe
| | - Gwenzi Farai
- Zimbabwe Technical Training and Education Center for Health (ZIMTTECH), Harare, Zimbabwe
| | - Hove Joseph
- Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe
| | - Tinashe Munyaradzi
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Rutsito Olban
- Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe
| | - Chatikobo Pesanai
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Tshimanga Mufuta
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | | | | | | | - Holec Marrianne
- International Training and Education Center for Health (I-TECH), Seattle, WA USA
| | - Barnhart Scott
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Seattle, WA USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Seattle, WA USA
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Doyle AM, Bandason T, Dauya E, McHugh G, Grundy C, Dringus S, Dziva Chikwari C, Ferrand RA. Mobile Phone Access and Implications for Digital Health Interventions Among Adolescents and Young Adults in Zimbabwe: Cross-Sectional Survey. JMIR Mhealth Uhealth 2021; 9:e21244. [PMID: 33439136 PMCID: PMC7840276 DOI: 10.2196/21244] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/08/2020] [Accepted: 10/30/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Mobile phones may help young people (YP) access health information and support health service engagement. However, in low-income settings there is limited knowledge on YP's phone and internet access to inform the feasibility of implementing digital health interventions. OBJECTIVE We investigated access to information and communication technologies among adolescents and young adults in Zimbabwe. METHODS A cross-sectional population-based survey was conducted from October to December 2018 among YP aged 13-24 years in 5 communities in urban and peri-urban Harare and Mashonaland East, Zimbabwe. Consenting YP completed a self-completed tablet-based questionnaire on mobile phone ownership and use, and use of the internet. The primary outcome was the proportion who reported owning a mobile phone. Secondary outcomes included phone and internet access and use behavior, and ownership and use of other technological devices. Multivariable logistic regression was used to investigate factors associated with mobile phone ownership and with internet access, with adjustment for the one-stage cluster sampling design. A priori exploratory variables were age, sex, marital status, and urban/peri-urban residence. RESULTS A total of 634/719 (88.2%) eligible YP, mean age 18.0 years (SD 3.3) and 62.6% (397/634) females, participated. Of the YP interviewed, 62.6% (396/633; 95% CI 58.5-66.5) reported owning a phone and a further 4.3% (27/633) reported having access to a shared phone. Phone ownership increased with age: 27.0% (43/159) of 13-15-year olds, 61.0% (72/118) of 16-17-year olds, 71.5% (103/144) of 18-19-year olds, and 84.7% (171/202) of 20-24-year olds (odds ratio [OR] 1.4, 95% CI 1.3-1.5) per year increase. Ownership was similar among females and males: 61.0% (236/387; 95% CI 55.6-66.1) versus 64.8% (153/236; 95% CI 57.8-71.2), age-adjusted OR 0.7 (95% CI 0.5-1.1); higher in those with secondary level education compared to primary or no education: 67.1% (346/516; 95% CI 62.6-71.2) versus 26% (21/82; 95% CI 16.4-37.7), age-adjusted OR 2.3 (95% CI 1.1-4.8); and similar across other sociodemographic factors. YP reported that 85.3% (361/423) of phones, either owned or shared, were smartphones. Among phone owners, the most commonly used phone app was WhatsApp (71.2%, 282/396), and 16.4% (65/396) reported having ever used their phone to track their health. A total of 407/631 (64.5%; 95% CI 60.3-68.5) currently had access to the internet (used in last 3 months on any device) with access increasing with age (OR 1.2, 95% CI 1.2-1.3 per year increase). In age-adjusted analysis, internet access was higher among males, the unmarried, those with a higher level of education, phone owners, and those who had lived in the community for more than 1 year. The aspect of the internet that YP most disliked was unwanted sexual (29.2%, 136/465) and violent (13.1%, 61/465) content. CONCLUSIONS Mobile phone-based interventions may be feasible in this population; however, such interventions could increase inequity, especially if they require access to the internet. Internet-based interventions should consider potential risks for participants and incorporate skill-building sessions on safe internet and phone use.
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Affiliation(s)
- Aoife M Doyle
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Ethel Dauya
- Biomedial Resarch and Training Institute, Harare, Zimbabwe
| | - Grace McHugh
- Biomedial Resarch and Training Institute, Harare, Zimbabwe
| | - Chris Grundy
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Stefanie Dringus
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Chido Dziva Chikwari
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Biomedial Resarch and Training Institute, Harare, Zimbabwe
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Rashida A Ferrand
- Biomedial Resarch and Training Institute, Harare, Zimbabwe
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Feldacker C, Murenje V, Makunike-Chikwinya B, Hove J, Munyaradzi T, Marongwe P, Balachandra S, Mandisarisa J, Holec M, Xaba S, Sidile-Chitimbire V, Tshimanga M, Barnhart S. Balancing competing priorities: Quantity versus quality within a routine, voluntary medical male circumcision program operating at scale in Zimbabwe. PLoS One 2020; 15:e0240425. [PMID: 33048977 PMCID: PMC7553309 DOI: 10.1371/journal.pone.0240425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/26/2020] [Indexed: 12/11/2022] Open
Abstract
Background Since 2013, the ZAZIC consortium supported the Zimbabwe Ministry of Health and Child Care (MOHCC) to implement a high quality, integrated voluntary medical male circumcision (VMMC) program in 13 districts. With the aim of significantly lowering global HIV rates, prevention programs like VMMC make every effort to achieve ambitious targets at an increasingly reduced cost. This has the potential to threaten VMMC program quality. Two measures of program quality are follow-up and adverse event (AE) rates. To inform further VMMC program improvement, ZAZIC conducted a quality assurance (QA) activity to assess if pressure to do more with less influenced program quality. Methods Key informant interviews (KIIs) were conducted at 9 sites with 7 site-based VMMC program officers and 9 ZAZIC roving team members. Confidentiality was ensured to encourage candid conversation on adherence to VMMC standards, methods to increase productivity, challenges to target achievement, and suggestions for program modification. Interviews were recorded, transcribed and analyzed using Atlas.ti 6. Results VMMC teams work long hours in diverse community settings to reach ambitious targets. Rotating, large teams of trained VMMC providers ensures meeting demand. Service providers prioritize VMMC safety procedures and implement additional QA measures to prevent AEs among all clients, especially minors. However, KIs noted three areas where pressure for increased numbers of clients diminished adherence to VMMC safety standards. For pre- and post-operative counselling, MC teams may combine individual and group sessions to reach more people, potentially reducing client understanding of critical wound care instructions. Second, key infection control practices may be compromised (handwashing, scrubbing techniques, and preoperative client preparation) to speed MC procedures. Lastly, pressure for client numbers may reduce prioritization of patient follow-up, while client-perceived stigma may reduce care-seeking. Although AEs appear well managed, delays in AE identification and lack of consistent AE reporting compromise program quality. Conclusion In pursuit of ambitious targets, healthcare workers may compromise quality of MC services. Although risk to patients may appear minimal, careful consideration of the realities and risks of ambitious target setting by donors, ministries, and implementing partners could help to ensure that client safety and program quality is consistently prioritized over productivity.
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Affiliation(s)
- Caryl Feldacker
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- * E-mail:
| | - Vernon Murenje
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | | | - Joseph Hove
- Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe
| | - Tinashe Munyaradzi
- Zimbabwe Community Health Intervention Project (ZICHIRE), Harare, Zimbabwe
| | - Phiona Marongwe
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | - Shirish Balachandra
- United States Centers for Disease Control and Prevention, Division of Global HIV & TB, Harare, Zimbabwe
| | - John Mandisarisa
- United States Centers for Disease Control and Prevention, Division of Global HIV & TB, Harare, Zimbabwe
| | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | | | | | - Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZICHIRE), Harare, Zimbabwe
| | - Scott Barnhart
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
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Babigumira JB, Barnhart S, Mendelsohn JM, Murenje V, Tshimanga M, Mauhy C, Holeman I, Xaba S, Holec MM, Makunike-Chikwinya B, Feldacker C. Cost-effectiveness analysis of two-way texting for post-operative follow-up in Zimbabwe's voluntary medical male circumcision program. PLoS One 2020; 15:e0239915. [PMID: 32997710 PMCID: PMC7526887 DOI: 10.1371/journal.pone.0239915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 09/16/2020] [Indexed: 12/21/2022] Open
Abstract
Objective Although adverse events (AEs) following voluntary medical male circumcision (VMMC) are rare, their prompt ascertainment and management is a marker of quality care. The use of two-way text messaging (2wT) for client follow-up after VMMC reduces the need for clinic visits (standard of care (SoC)) without compromising safety. We compared the cost-effectiveness of 2wT to SoC for post-VMMC follow-up in two, high-volume, public VMMC sites in Zimbabwe. Materials and methods We developed a decision-analytic (decision tree) model of post-VMMC client follow-up at two high-volume sites. We parameterized the model using data from both a randomized controlled study of 2wT vs. SoC and from the routine VMMC program. The perspective of analysis was the Zimbabwe government (payer). The time horizon covered the time from VMMC to wound healing. Costs included text messaging; both in-person and outreach follow-up; and AE management. Costs were estimated in 2018 U.S. dollars. The outcome of analysis was AE yield relative to the globally accepted safety standard of a 2% AE rate. We estimated the incremental cost per percentage increase in AE ascertainment and the incremental cost per additional AE identified. We conducted univariate and probabilistic sensitivity analyses. Results 2wT increased the costs due to text messaging by $4.42 but reduced clinic visit costs by $2.92 and outreach costs by $3.61 –a net savings of $2.10. 2wT also increased AE ascertainment by 50% (92% AE yield in 2wT compared to 42% AE yield in SoC). Therefore, 2wT dominated SoC in the incremental analysis: 2wT was less costly and more effective. Results were generally robust to univariate and probabilistic sensitivity analysis. Conclusions 2wT is cost-effective for post-VMMC follow-up in Zimbabwe. Countries in which VMMC is a high-priority HIV prevention intervention should consider this mHealth intervention to reduce overall cost per VMMC, increasing the likelihood of current and future VMMC program sustainability.
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Affiliation(s)
- Joseph B. Babigumira
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, United States of America
- * E-mail:
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Joanna M. Mendelsohn
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Vernon Murenje
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | - Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe
| | - Christina Mauhy
- Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe
| | | | | | - Marrianne M. Holec
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | | | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
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Feldacker C, Holeman I, Murenje V, Xaba S, Korir M, Wambua B, Makunike-Chikwinya B, Holec M, Barnhart S, Tshimanga M. Usability and acceptability of a two-way texting intervention for post-operative follow-up for voluntary medical male circumcision in Zimbabwe. PLoS One 2020; 15:e0233234. [PMID: 32544161 PMCID: PMC7297350 DOI: 10.1371/journal.pone.0233234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 04/30/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Voluntary medical male circumcision (MC) is safe and effective. Nevertheless, MC programs require multiple post-operative visits. In Zimbabwe, a randomized control trial (RCT) found that post-operative two-way texting (2wT) between clients and MC providers instead of in-person reviews reduced provider workload and safeguarded patient safety. A critical component of the RCT assessed usability and acceptability of 2wT among providers and clients. These findings inform scale-up of the 2wT approach to post-operative follow-up. METHODS The RCT assigned 362 adult MC clients with cell phones into 2wT; these men responded to 13 automated daily texts supported by interactive texting or in-person follow-up, when needed. A subset of 100 texting clients filled a self-administered usability survey on day 14. 2wT acceptability was ascertained via 2wT response rates. Among 2wT providers, eight key informant interviews focused on 2wT acceptability and usability. Influences of wage and age on response rates and client-reported potential AEs were explored using linear and logistic regression models, respectively. RESULTS Clients felt confident, comfortable, satisfied, and well-supported with 2wT-based follow-up; few noted texting challenges or concerns about healing. Clients felt 2wT saved them time and money. Response rates (92%) suggested 2wT acceptability. Both clients and providers felt 2wT was highly usable. Providers noted 2wT saved them time, empowered clients to engage in their healing, and closed gaps in MC service quality. For scale, providers reinforced good post-operative counseling on AEs and texting instructions. Wage and age did not influence text response rates or potential AE texts. CONCLUSION Results strongly suggest that 2wT is highly usable and acceptable for providers and patients. Men with concerns solicited provider guidance and reassurance offered via text. Providers noted that men engaged proactively in their healing. 2wT between providers and patients should be expanded for MC and considered for other short-term care contexts. The trial is registered on ClinicalTrials.gov, trial NCT03119337, and was activated on April 18, 2017. https://clinicaltrials.gov/ct2/show/NCT03119337.
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Affiliation(s)
- Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Isaac Holeman
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Medic Mobile, Nairobi, Kenya
| | - Vernon Murenje
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | | | | | | | | | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe
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