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Background: Community-based mobile phone programs can complement gaps in clinical services for prevention of mother-to-child transmission (PMTCT) of HIV in areas with poor infrastructure and personnel shortages. However, community and health worker perceptions on optimal mobile phone communication for PMTCT are underexplored. This study examined what specific content and forms of mobile communication are acceptable to support PMTCT. Methods. Qualitative methods using focus groups and in-depth interviews were conducted in two district hospitals in Nyanza Province, Kenya. A total of 45 participants were purposefully selected, including HIV-positive women enrolled in PMTCT, their male partners, community health workers, and nurses. Semi-structured discussion guides were used to elicit participants’ current mobile phone uses for PMTCT and their perceived benefits and challenges. We also examined participants’ views on platform design and gender-tailored short message service (SMS) messages designed to improve PMTCT communication and male involvement. Results: Most participants had access to a mobile phone and prior experience receiving and sending SMS, although phone sharing was common among couples. Mobile phones were used for several health-related purposes, primarily as voice calls rather than texts. The perceived benefits of mobile phones for PMTCT included linking with health workers, protecting confidentiality, and receiving information and reminders. Men and women considered the gender-tailored SMS as a catalyst for improving PMTCT male involvement and couples’ communication. However, informative messaging relayed safely to the intended recipient was critical. In addition, health workers emphasized the continual need for in-person counseling coupled with, rather than replaced by, mobile phone reinforcement. For all participants, integrated and neutral text messaging provided antenatally and postnatally was most preferred, although not all topics or text formats were equally acceptable. Conclusions: Given the ubiquity of mobile phones in Kenya and current health-related uses of mobile phones, a PMTCT mobile communications platform holds considerable potential. This pre-intervention assessment of community and health worker preferences yielded valuable information on the complexities of design and implementation. An effective PMTCT mobile platform engaging men and women will need to address contexts of non-disclosure, phone sharing, and linkages with existing community and facility-based services. © 2013 Jennings et al.; licensee BioMed Central Ltd.
A qualitative study was conducted using focus group discussions (FGDs) with HIV-positive pregnant women, their male partners, and community health workers (CHWs), as well as in-depth interviews (IDIs) with facility-based nurses providing PMTCT services. Two district hospitals with existing PMTCT programs were selected from Kendu Bay and Rachuonyo Districts in Nyanza Province, Kenya. Nyanza Province has the highest HIV prevalence in Kenya at 14% with an estimated HIV prevalence among pregnant women of 8% [16]. The Kenyan Ministry of Health estimates that over 18,000 women were identified as HIV-positive in Nyanza Province [17]. Antenatal care (ANC) coverage in Kenya is high (92%), while skilled birth attendance remains low (44%) [16]. Only a minority of HIV-infected women and their infants successfully complete the PMTCT cascade through use of maternal and infant antiretroviral therapy and safe infant feeding. For example, 65% of HIV-infected women were initiated on antiretroviral prophylaxis while only 20% of HIV-exposed infants were tested for HIV at 6 weeks [17]. An estimated 17.3 million Kenyans aged 15 and older own a mobile phone [18], and 86% and 92% of women and men, respectively, reported using a mobile phone in the last week primarily for sending and receiving SMS messages [19]. HIV-positive postpartum women were purposively recruited to participate in the study by CHWs who were oriented on the study’s objective and selection criteria. Women older than 18 years of age who were currently enrolled in or had completed PMTCT less than two years prior were eligible for the study along with their male partner. All on-site or available PMTCT community- and facility-based health workers were selected from each of the two district hospitals and the surrounding catchment area. An open-ended topic guide for women and their male partners was used to elicit information on five core themes: current mobile phone use and ownership, perceived benefits and challenges of using mobile phones for PMTCT, views on priority messaging for SMS promotion of PMTCT, optimal design of a mobile phone-based PMTCT communication platform, and mobile-promoted male involvement for PMTCT. To examine current mobile use and ownership, participants were asked about their access to phones, including examples of how they had used mobile phones previously for health-related purposes. They were also asked about current challenges that women, partners, or health workers face in supporting PMTCT and how mobile phones might be employed to mitigate those challenges. To explore views on priority messages, twelve gender-tailored SMS mock-ups were presented across PMTCT core behaviors. Six SMS mock-ups were tailored for women enrolled in PMTCT services, and six were tailored for their male partners. The SMS mock-ups were translated from English to Kiswahili and the local language, Luo, and back-translated. Participants were asked to read the mock-up in the language of their choice, and describe what they understood it to convey, including any recommendations. To examine platform design features, participants were asked how often, when, or how long they would like to receive SMS for PMTCT and in what languages, including preferences for SMS versus phone calling. To examine mobile-promoted male involvement for PMTCT, participants were asked how mobile phones could be used to encourage male participation in PMTCT. Facility-based nurses and CHWs were asked to review the SMS mock-ups and describe their envisioned role in the mHealth PMTCT platform. A total of six FGDs were conducted: two with women enrolled in PMTCT, two with male partners, and two with CHWs. Four IDIs with nurses were also conducted. This represented a total of 45 participants: 17 HIV-positive postpartum women, 12 male partners, 12 CHWs, and 4 nurses. All of the FGDs and IDIs were led by three social scientists with experience conducting qualitative research. The sessions were audio recorded and conducted in English, Kiswahili, or Luo, as selected by the participants. Each session lasted approximately 90 to 120 minutes. Focus groups were selected to provide an interactive format to capture multiple views on each proposed thematic area as a result of the dynamics and discussion of each group. Following the session, information on age, education, marital status, employment status, phone ownership, and prior experience sending and receiving SMS were also collected. Several stakeholder meetings with PMTCT advisors and program staff were likewise conducted as part of the SMS mock-up and tool development process. FGDs were translated and transcribed verbatim into English. Data analysis of the narrative data was conducted in two phases using a thematic approach. First, during data collection, FGDs were synthesized in detail by the research team immediately after each session to guide subsequent discussions. The team debriefings also helped to determine when saturation had been achieved and no new information had emerged. In the second phase, a manual preliminary analysis of the narrative data aimed to assemble the responses according to the pre-set themes in the FGD topic guide, which were then refined according to emergent themes. The analysis’ culminating step was to highlight relevant quotes provided in the text to illustrate major findings. To enhance the credibility of results, the research team compared findings from each of the study’s sub-groups and organized a verification meeting with program advisors to examine the extent to which the research captured internally valid and dependable information. This included a review of typed field notes and confirmation of translation and transcription files. Demographic and contextual data were also obtained to facilitate the transferability of findings to similar contexts. The study additionally aimed to ensure concepts of data quality in qualitative research concerning authenticity and fairness were addressed by including direct quotes and a diverse range of views, including varying points of interpretation. This study received ethics approval by the Kenyatta National Hospital, University of Nairobi Ethics and Research Committee in Nairobi, Kenya. Written informed consent was obtained for participation in the study as well as audio recording of the discussion. Participants were also asked to keep all discussions confidential. Data collected as part of the study were not linked to individual or personal identifiers.
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