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Background: Most of the world’s women living with human immunodeficiency virus (HIV) reside in sub-Saharan Africa. Although efforts to reduce mother-to-child transmission are underway, obtaining complete and accurate data from rural clinical sites to track progress presents a major challenge. Objective: To describe the acceptability and feasibility of mobile phones as a tool for clinic-based face-to-face data collection with pregnant women living with HIV in South Africa. Methods: As part of a larger clinic-based trial, 16 interviewers were trained to conduct mobile phone-assisted personal interviews (MPAPI). These interviewers (participant group 1) completed the same short questionnaire based on items from the Technology Acceptance Model at 3 different time points. Questions were asked before training, after training, and 3 months after deployment to clinic facilities. In addition, before the start of the primary intervention trial in which this substudy was undertaken, 12 mothers living with HIV (MLH) took part in a focus group discussion exploring the acceptability of MPAPI (participant group 2). Finally, a sample of MLH (n=512) enrolled in the primary trial were asked to assess their experience of being interviewed by MPAPI (participant group 3). Results: Acceptability of the method was found to be high among the 16 interviewers in group 1. Perceived usefulness was reported to be slightly higher than perceived ease of use across the 3 time points. After 3 months of field use, interviewer perceptions of both perceived ease of use and perceived usefulness were found to be higher than before training. The feasibility of conducting MPAPI interviews in this setting was found to be high. Network coverage was available in all clinics and hardware, software, cost, and secure transmission to the data center presented no significant challenges over the 21-month period. For the 12 MHL participants in group 2, anxiety about the multimedia capabilities of the phone was evident. Their concern centered on the possibility that their privacy may be invaded by interviewers using the mobile phone camera to photograph them. For participants in group 3, having the interviewer sit beside vs across from the interviewee during the MPAPI interview was received positively by 94.7% of MHL. Privacy (6.3%) and confidentiality (5.3%) concerns were low for group 3 MHL. Conclusions: Mobile phones were found both to be acceptable and feasible in the collection of maternal and child health data from women living with HIV in South Africa.
This study was nested within a larger clinic-based randomized cluster trial known as Project Masihambisane (“let us walk together”; Clinicaltrials.gov {“type”:”clinical-trial”,”attrs”:{“text”:”NCT00972699″,”term_id”:”NCT00972699″}}NCT00972699) [23]. The primary study aimed to improve mental and physical health outcomes of HIV-positive mothers and their babies by supplementing the PMTCT with paraprofessional peer mentors. Using a mixed-methods design, qualitative data from a single, small focus group were supplemented with 2 quantitative questionnaires collected using a mobile phone survey application. Paradata, or data on the data collection process, were gathered in order to examine the feasibility of mobile phone-assisted personal interviewing (MPAPI). The MPAPI survey platform was supplied by Mobenzi Researcher [24], a commercial vendor based in South Africa. The solution offered by Mobenzi includes both a mobile application and a Web portal. The Java Platform Micro Edition (Java ME) application runs on all handsets compliant with mobile information device profile (MIDP) 2.0. It provides full survey functionality, including the ability to create various question types, mark fields as mandatory, and intelligently manage survey branching (Figure 1). The software is now also available for Android handsets. The Java ME application was installed on Nokia E61 handsets. These mobile phones run on the Symbian S60 operating system, have a 2.9-inch thin film transistor screen, 64 megabyte random-access memory (RAM), Bluetooth, Wi-Fi, a QWERTY keyboard, and a 1500 milliamp hour battery. Example of the Mobenzi Researcher application running on a Nokia handset. Once installed, the software was able to communicate, using either Wi-Fi or a cellular data link, with the Mobenzi server. The server provided, for download, the surveys designed using the Web portal (Figure 2). The server also received, stored, and aggregated the surveys completed on the handset (Figures 3--5)5) for download as a comma-separated file. Mobenzi offered programmatic access to both surveys and data through an application programming interface (API). Example of Mobenzi Researcher Web portal: survey design. Example of Mobenzi Researcher Web portal: interviewer management. Example of Mobenzi Researcher Web portal: data overview and export. If no data connection was available at the time of survey completion, the response was saved on the handset until a connection was re-established. The MTN mobile network was used to upload survey responses from the handset to server. Figure 6 depicts a typical example of a fieldworker conducting a mobile phone–assisted personal interview outside a primary health care facility. Example of Mobenzi Researcher in field use. Example of Mobenzi Researcher Web portal: charting and analytics. Three groups of participants took part in this study. The first group of participants (participant group 1) included the 16 interviewers recruited and trained on MPAPI for the primary study. Although these participants were all familiar with pen-and-paper questionnaires, none had ever used MPAPI. Before receiving any training on MPAPI, the group were asked to complete a short questionnaire with items from the Technology Acceptance Model proposed by Davis [25]. The scale contains 12 items, 6 relating to the perceived usefulness of mobile phones for research purposes and 6 related to the perceived ease of their use (Table 1). Each item was rated on a 5-point Likert-type scale ranging from extremely likely to extremely unlikely. Following 3 days of training, a posttraining assessment was conducted using the same questionnaire. After completing training, the interviewers were dispatched to 8 primary health care clinics in a rural district typical of those found in the region where the interviewers were originally interviewing pregnant women living with HIV for the primary study. After 3 months, the questionnaire was administered for a third time to gauge if use of the phone in the field had altered perceptions and attitudes toward the tool. Technology Acceptance Model scale. The second group (participant group 2), recruited for participation in the focus group, consisted of 12 pregnant women with HIV living in this region of South Africa who were enrolled through community forums set up for the larger study. Before the focus group was held, each woman was interviewed by a research assistant using a mobile phone. The questions asked ranged from general health questions about the participants’ knowledge of HIV to more sensitive questions about recent sexual activity, condom use, and disclosure of HIV status to their partners. After completing the questionnaire, the group was brought together to participate in a focus group about their experience. Five questions were designed to facilitate the discussion about general mobile phone ownership and their reactions to the interview conducted by mobile phone. The focus group lasted for an hour with extensive notes being taken about responses. The third group of participants (participant group 3) were pregnant women living with HIV recruited through the primary study. Participants were recruited in the Umgungundlovu Health District of KwaZulu-Natal, a province in South Africa with 10 million people, over half (57%) living in rural areas. The Umgungundlovu District includes 7 local authorities, has 48 fixed clinics, 4 community health centers, 9 tertiary hospitals, and an estimated population of some 995,000 persons according to a 2007 estimate [26]. From this district, 8 clinics were selected through a clinic audit conducted in December 2007. The selection criteria, applied to all potential clinics in the district during the audit, were presence of other research trials, clinic size, availability of antenatal and postnatal services, and uptake of antenatal and postnatal services at the clinic. The clinic audit resulted in the selection of 4 pairs of clinics for the study, matched on size (small vs large) and geography (rural vs urban). Women who met the eligibility criteria of being 18 years or older, less than 34 weeks pregnant, and planning to reside in the study area for the duration of their pregnancy were invited to participate in the primary study. If they accepted, a baseline health questionnaire was completed by an interviewer using a mobile phone survey application. Using a cross-sectional design and a continuous sampling strategy that started approximately halfway through the primary study, 512 of the 1204 women enrolled into the primary study were recruited to participate in this substudy. This cross-section of women completed a second questionnaire, again using MPAPI, in which they were asked to describe their views about the mobile phone survey. A thematic analysis was performed on the qualitative data generated by focus group discussions. This data was supplemented with exploratory data analysis techniques, such as frequency analysis and chi-square (χ2) statistics, performed on the quantitative questionnaire data. Univariate analysis was used to analyze perceived ease of use and perceived usefulness scale data. Data was downloaded as comma-separated values from the online Mobile Research database. This comma-separated values file was then imported into SPSS 19 (IBM Corp, Armonk, NY, USA). A team of 16 data collectors administered the questionnaire and 2 coordinators employed by the primary trial supervised all aspects of the study in the field. The coordinators’ role included managing informed consent, supporting field activities, and monitoring data quality through quality assurance checks and ongoing training and supervision of interviewers. Ethical approval for the study was obtained from the Committee for Research on Human Subjects (Medical) Witwatersrand Human Ethics Committee (M091035). A study information sheet was presented to all participants and the study was explained in detail before participants signed a form giving written consent to participate.
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