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Kiruthu-Kamamia C, Weldemariam H, Chipanda M, Huwa J, Seyani J, Chirwa H, Kudzala A, Thawani A, Chintedza J, Sande O, Chiwaya G, Tweya H, Pavlova M, Groot W, Feldacker C. Cost-effectiveness analysis of two-way texting (2wT) intervention to improve ART retention among newly-initiated antiretroviral therapy clients in Malawi. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.17.24305960. [PMID: 38699324 PMCID: PMC11065025 DOI: 10.1101/2024.04.17.24305960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Background Retention in HIV care is crucial for improved health outcomes. Malawi has a high HIV prevalence and struggles with retention despite significant progress in controlling the epidemic. Mobile health (mHealth) interventions, such as two-way texting (2wT), have shown promise in improving anti-retroviral therapy (ART) retention. We explore the cost-effectiveness of a 2wT intervention in Lighthouse Trust's Martin Preuss Center (MPC) in Lilongwe, Malawi, that sends automated SMS visit reminders, weekly motivational messages, and supports direct communication between clients and healthcare workers. Methods Costs and retention rates were compared between 2wT and standard of care (SOC) for 468 clients enrolled in each. Incremental cost-effectiveness ratios (ICERs) were calculated. Scenario analyses were conducted to estimate costs if 2wT expanded. Results The 2wT group had higher retention (80%) than SOC (67%) at 12 months post-ART initiation. For 468 clients, the total annual costs for 2wT were $36,670.38 as compared to SOC costs at $33,458.72, resulting in an ICER of $24,705. Among scenarios, the ICER was -$105,315 if 2wT expanded to all new clients (2678 at MPC and -$723,739 as 2wT expanded to other four high-burden facilities (2901 clients), suggesting high cost savings if 2wT was effectively scaled. Conclusion The 2wT intervention appears cost-effective to improve ART retention among new ART initiates in a high-burden ART clinic. While mHealth interventions have potential limitations, their benefits in improving patient outcomes and cost savings support their integration into HIV care programs.
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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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Mbwayo AW, Mathai M, Mutavi T, Waruinge S, Triplett N, Concepcion T, Collins PY, Dorsey S. Training community health volunteers to use mobile platform during the COVID-19 pandemic: The Kenya experience. Glob Ment Health (Camb) 2024; 11:e38. [PMID: 38618483 PMCID: PMC11016365 DOI: 10.1017/gmh.2024.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 04/16/2024] Open
Abstract
This study describes an alternative to face-to-face training method for community health volunteers (CHVs) as used by a collaborative group from the University of Nairobi, University of Washington and the Nairobi Metropolitan Mental Health Team during the COVID-19 lockdown in Kenya. This qualitative study describes the experiences of 17 CHVs enrolled in a training study, required to utilize different digital platforms (Google Meet or Jitsi) as a training forum for the first time. Verbatim extracts of the participants' daily experiences are extracted from a series of write-ups in the group WhatsApp just before the training. Daily failures and success experiences in joining a Google meet or Jitsi are recorded. Then, 17 participants, 10 women and 7 men, aged between 21 and 51 years (mean = 33), owning a smartphone, were enrolled in the study. None had used Jitsi or Google meet before. Different challenges were reported in login to either and a final decision to use Jitsi, which became the training platform. Training CHVs to deliver a psychosocial intervention using smartphones is possible. However, the trainer must establish appropriate and affordable methods when resources are constrained.
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Affiliation(s)
- Anne W. Mbwayo
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya
| | - Muthoni Mathai
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya
| | - Teresia Mutavi
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya
| | - Stella Waruinge
- Department of Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - Noah Triplett
- Department of Psychology, Department of Global Health, University of Washington, Seattle, USA
| | - Tessa Concepcion
- Department of Psychology, Department of Global Health, University of Washington, Seattle, USA
| | - Pamela Y. Collins
- Department of Mental Health, Johns Hopkins University, Baltimore, USA
| | - Shannon Dorsey
- Department of Psychology, Department of Global Health, University of Washington, Seattle, USA
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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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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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El Tantawi M, Lam WYH, Giraudeau N, Virtanen JI, Matanhire C, Chifamba T, Sabbah W, Gomaa N, Al-Maweri SA, Uribe SE, Mohebbi SZ, Hasmun N, Guan G, Polonowita A, Khan SB, Pisano M, Ellakany P, Baraka MM, Ali AA, Orellana Centeno JE, Pavlic V, Folayan MO. Teledentistry from research to practice: a tale of nineteen countries. FRONTIERS IN ORAL HEALTH 2023; 4:1188557. [PMID: 37397348 PMCID: PMC10311964 DOI: 10.3389/froh.2023.1188557] [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: 03/17/2023] [Accepted: 05/26/2023] [Indexed: 07/04/2023] Open
Abstract
Aim The COVID-19 pandemic has accelerated teledentistry research with great interest reflected in the increasing number of publications. In many countries, teledentistry programs were established although not much is known about the extent of incorporating teledentistry into practice and healthcare systems. This study aimed to report on policies and strategies related to teledentistry practice as well as barriers and facilitators for this implementation in 19 countries. Methods Data were presented per country about information and communication technology (ICT) infrastructure, income level, policies for health information system (HIS), eHealth and telemedicine. Researchers were selected based on their previous publications in teledentistry and were invited to report on the situation in their respective countries including Bosnia and Herzegovina, Canada, Chile, China, Egypt, Finland, France, Hong Kong SAR, Iran, Italy, Libya, Mexico, New Zealand, Nigeria, Qatar, Saudi Arabia, South Africa, United Kingdom, Zimbabwe. Results Ten (52.6%) countries were high income, 11 (57.9%) had eHealth policies, 7 (36.8%) had HIS policies and 5 (26.3%) had telehealth policies. Six (31.6%) countries had policies or strategies for teledentistry and no teledentistry programs were reported in two countries. Teledentistry programs were incorporated into the healthcare systems at national (n = 5), intermediate (provincial) (n = 4) and local (n = 8) levels. These programs were established in three countries, piloted in 5 countries and informal in 9 countries. Conclusion Despite the growth in teledentistry research during the COVID-19 pandemic, the use of teledentistry in daily clinical practice is still limited in most countries. Few countries have instituted teledentistry programs at national level. Laws, funding schemes and training are needed to support the incorporation of teledentistry into healthcare systems to institutionalize the practice of teledentistry. Mapping teledentistry practices in other countries and extending services to under-covered populations increases the benefit of teledentistry.
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Affiliation(s)
- Maha El Tantawi
- Department of Pediatric Dentistry and Dental Public Health, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Walter Yu Hang Lam
- Prosthodontics, Restorative Dental Sciences, Faculty of Dentistry, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | | | - Jorma I. Virtanen
- Institute of Dentistry, Faculty of Medicine, University of Turku, Turku, Finland
| | - Cleopatra Matanhire
- Department of Oral Health, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Timothy Chifamba
- Department of Oral Health, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Wael Sabbah
- Centre for Host Microbiome Interactions, King’s College London, London, United Kingdom
| | - Noha Gomaa
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Sadeq Ali Al-Maweri
- Department of Pre-Clinical Oral Health Sciences, College of Dental Medicine, QU Health, Qatar University, Doha, Qatar
| | - Sergio E. Uribe
- Department of Conservative Dentistry and Oral Health, Riga Stradins University, Riga, Latvia
- School of Dentistry, Universidad Austral de Chile, Valdivia, Chile
- Baltic Biomaterials Centre of Excellence, Headquarters at Riga Technical University, Riga, Latvia
| | - Simin Z. Mohebbi
- Research Center for Caries Prevention, Dentistry Research Institute, and Department of Community Oral Health, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Noren Hasmun
- Department of Oral Sciences, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Guangzhao Guan
- Department of Oral Sciences, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Ajith Polonowita
- Department of Oral Sciences, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Sadika Begum Khan
- Department of Prosthetic Dentistry, Faculty of Dentistry, University of the Western Cape, Cape Town, South Africa
| | - Massimo Pisano
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, Italy
| | - Passent Ellakany
- Department of Substitutive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Marwa Mohamed Baraka
- Department of Pediatric Dentistry and Dental Public Health, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | | | | | - Verica Pavlic
- Department of Periodontology and Oral Medicine, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
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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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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 developing digital health interventions: usability and acceptability of a two-way texting retention intervention in a public HIV clinic in Lilongwe, Malawi. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.01.09.23284326. [PMID: 36711633 PMCID: PMC9882492 DOI: 10.1101/2023.01.09.23284326] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background New initiates on antiretroviral therapy (ART) are at high risk of treatment discontinuation, putting their health at risk. In low-resource settings, like Malawi, appropriate digital health applications must fit into local connectivity and resource constraints. Target users' perspectives are critical for app usability, buy-in and optimization. We describe the formative stages of the design of a two-way text-based (2wT) system of tailored reminders and adherence messages for new ART initiates and share results from key informant interviews with HCWs focused on app usability and acceptability. Methods Using a co-creation approach with clients, clinical, technical and evaluation teams and over app development, we held four informal user feedback sessions, a small pilot with 50 clients, and ten key informant (KIIs) to deepen our understanding of healthcare workers (HCWs) needs, acceptability and usability. Results Formative research informed the design of interactive client-to-HCW communication, refining of the language and timing of weekly text blast motivational messages and tailored client-specific visit reminders. Informal feedback from HCW stakeholders also informed educational materials to enhance 2wT client understanding of how to report transfers, request visit date changes and ask questions related to their visits. In KII, HCWs noted their appreciation for the co-creation process, believing that the participatory HCD process and responsive design team enabled the development of a highly acceptable and usable 2wT digital tool. HCWs also suggested future improvements to promote inclusion of clients of varying literacy levels and economic backgrounds as well as integrating with other health platforms to improve uptake of 2wT. Conclusions Inclusion of HCWs increased perceptions of app usability and acceptability among HCWs. HCWs believe that 2wT will improve on-time ART visit attendance and provide valuable early retention in care support. The co-creation approach appears successful in designing an app that will meet HCW needs and, therefore, support client adherence to visits.
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Affiliation(s)
| | | | | | | | | | | | | | - Hannock Tweya
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | - Caryl Feldacker
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
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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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