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Background: Over the past decade, mobile health has steadily increased in low-income and middle-income countries. However, few platforms have been able to sustainably scale up like the MomConnect program in South Africa. NurseConnect was created as a capacity building component of MomConnect, aimed at supporting nurses and midwives in maternal and child health. The National Department of Health has committed to expanding NurseConnect to all nurses across the country, and an evaluation of the current user experience was conducted to inform a successful scale up. Objective: This study aims to evaluate the perception and use of NurseConnect by nurses and midwives to produce feedback that can be used to optimize the user experience as the platform continues to scale up. Methods: We conducted focus group discussions and in-depth interviews with 110 nurses and midwives from 18 randomly selected health care facilities across South Africa. Questions focused on mobile phone use, access to medical information and their experience with NurseConnect registration, as well as the content and different platforms. Results: All participants had mobile phones and communication through calls and messaging was the main use in both personal and work settings. Of 110 participants, 108 (98.2%) had data-enabled phones, and the internet, Google, and apps (South African National Department of Health Guidelines, iTriage, Drugs.com) were commonly used, especially to find information in the work setting. Of 110 participants, 62 (56.4%) were registered NurseConnect users and liked the message content, especially listeriosis and motivational messages, which created behavioral change in some instances. The mobisite and helpdesk, however, were underutilized because of a lack of information surrounding these platforms. Some participants did not trust medical information from websites and had more confidence in apps, while others associated a “helpdesk” with a call-in service, not a messaging one. Many of the unregistered participants had not heard of NurseConnect, and some cited data and time constraints as barriers to both registration and uptake. Conclusions: Mobile and smartphone penetration was very high, and participants often used their phone to find medical information. The NurseConnect messages were well-liked by all registered participants; however, the mobisite and helpdesk were underutilized owing to a lack of information and training around these platforms. Enhanced marketing and training initiatives that optimize existing social networks, as well as the provision of data and Wi-Fi, should be explored to ensure that registration improves, and that users are active across all platforms.
The NurseConnect evaluation in this paper specifically refers to the collection and evaluation of qualitative data from focus group discussion (FGDs) and in-depth interviews (IDIs) with nurses and midwives from selected facilities across South Africa. Of note, this paper does not evaluate any quantitative data pertaining to the outcomes or effectiveness of the NurseConnect platform, as these finding will be the focus of a separate publication. The NurseConnect platform was based on the Integrated Behavioral Model and Adult Learning Theory of change, where evidence indicates that engagement is the key to absorbing information from Web-based learning situations. Health care worker training and mentoring specialists compiled and designed the content with input from local doctors and nurses in the maternal health field. SMS text messages were presented in concise, simple language 2-3 times a week and often contained links to expanded papers on the mobisite. The mobisite could also be reached directly from the internet, and the helpdesk could be activated by responding to any of the SMS text messages. More recently, where nurses have smartphones, SMS text messages have been replaced by WhatsApp messages. The content was divided into 2 main categories—informational and motivational. The informational content aimed to improve users’ knowledge of maternal and child health, while the motivational content aimed to inspire users to make small actionable changes to increase productivity and happiness in their work. Figure 1 displays example messages, as well as a screenshot of the NurseConnect landing page. NurseConnect sample messages and mobisite. To minimize bias, we randomly chose 18 facilities to equally represent a national population by ensuring that all provinces, types of facilities (ie, hospitals, clinics, and community health centers [CHCs]), and regions (ie, urban, periurban, and rural) were included. Figure 2 details the names and locations of these 18 facilities. Facility locations. Ave: avenue; CHC: community health center. After provincial and district approval were obtained, facility visits were scheduled. Each facility was asked to provide a group of 6-8 registered staff to participate in an FGD or IDI, as well as a private room for the discussions to take place. Each site visit lasted from half a day to 3 days. Each FGD and IDI took between 15 minutes and 1 hour, depending on the operational demands of the facility and the active participation of the staff. All 18 approached facilities consented to participate in the research, and the site visits were conducted between December 12, 2017 and April 10, 2018. Convenience sampling provided a total of 110 nurses and midwives, who participated in the focus groups and interviews. Using a pretested and piloted guide, 2 experienced moderators facilitated the FGDs and IDIs, with the principal investigator being present for 15 of the 18 site visits. The decision to conduct an FGD or IDI depended on the number of available NurseConnect registered participants present at the facility during the data collection visit. The FGDs and IDIs were audiorecorded so that the conversations could later be transcribed, and the facilitator also documented notes after discussions. Although an option of answering in vernacular was presented, participants elected to speak English. A total of 18 FGDs and 9 IDIs were conducted during the site visits. All these recordings were transcribed by the principal investigator into Microsoft Word documents. A selection of transcripts was randomly selected and independently verified by another team member to ensure accuracy. A code list agreed upon by the evaluation team was constructed to define relevant codes and emergent themes. The transcripts were then uploaded to MAXQDA V 1.2 (Verbi Software) and investigated with the code list. All transcripts were coded by the principal investigator, while a selection of transcripts was independently coded by another study team member to ensure consistency. Upon completion, each code was concentrated into data reduction tables, then further refined into summary tables for reporting. Data were summarized into the themes of mobile use, registration, platforms, and user experience and content. Ethics approval for this evaluation was obtained from the University of the Witwatersrand Human Research Ethics Committee (M106976) on October 21, 2016. Participation in the data collection was voluntary. Consent forms were signed for both participation and voice recording.
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