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Background: Poor maternal, newborn and child health outcomes remain a major public health challenge in Nigeria. Mobile health (mHealth) interventions such as patient-held smart cards have been proposed as effective solutions to improve maternal health outcomes. Our objectives were to assess the acceptability and experiences of pregnant women with the use of a patient-held smartcard for antenatal services in Nigeria. Methods: Using focus group discussions, qualitative data were obtained from 35 pregnant women attending antenatal services in four Local Government Areas (LGAs) in Benue State, Nigeria. The audio-recorded data were transcribed and analyzed using framework analysis techniques such as the PEN-3 cultural model as a guide. Results: The participants were 18–44 years of age (median age: 24 years), all were married and the majority were farmers. Most of the participants had accepted and used the smartcards for antenatal services. The most common positive perceptions about the smartcards were their ability to be used across multiple health facilities, the preference for storage of the women’s medical information on the smartcards compared to the usual paper-based system, and shorter waiting times at the clinics. Notable facilitators to using the smartcards were its provision at the “Baby showers” which were already acceptable to the women, access to free medical screenings, and ease of storage and retrieval of health records from the cards. Costs associated with health services was reported as a major barrier to using the smartcards. Support from health workers, program staff and family members, particularly spouses, encouraged the participants to use the smartcards. Conclusion: These findings revealed that patient-held smart card for maternal health care services is acceptable by women utilizing antenatal services in Nigeria. Understanding perceptions, barriers, facilitators, and supportive systems that enhance the use of these smart cards may facilitate the development of lifesaving mobile health platforms that have the potential to achieve antenatal, delivery, and postnatal targets in a resource-limited setting.
Pregnant women residing in four local government areas (i.e., counties) in Benue State, Nigeria, were invited to participate in this study. Participants were part of the pilot smart card intervention in Benue State, Nigeria. Maximum variation purposive sampling approach was used to recruit participants of varying socio-demographic backgrounds (e.g., age, occupation, education, income, urban vs. rural residence, primigravidae vs. multiparous women, etc.) from their communities in these four counties. Recruitment continued until saturation was achieved during data collection. Data for this study were derived from focus group discussions (FGDs) held with participants in January and May, 2017. Focus group discussions were appropriate to explore the perceived barriers and/or facilitators that may influence use of mobile health technologies for MNCH services [35–37]. Further, focus groups provide the opportunity to identify lived experiences not captured in quantitative research and to probe deeply on comments made by group members [35–37]. All the women who were approached to participate agreed and provided written and verbal consent. Biodata was obtained from all participants. A public health professional (study co-investigator) trained in qualitative research methods, led the FGDs as the moderator with a research assistant trained in notetaking. This study was guided by the PEN-3 cultural model [38–40] which centralizes culture in the study of health beliefs, behaviors, and health outcomes. The PEN-3 cultural model was used as the theoretical framework to identify the perceptions, enablers, and nurturers related to the use of a mobile health technology for MNCH services. The PEN-3 cultural model consists of three primary domains: Cultural Identity, Relationships and Expectations, and Cultural Empowerment. Each domain comprises three factors that form the acronym PEN: Person, Extended Family, and Neighborhood (Cultural Identity domain); Perceptions, Enablers, and Nurturers (Relationships and Expectation domain); Positive, Existential and Negative (Cultural Empowerment domain). [39] Particularly, we used the relationships and expectations domain to explore perceptions about the smart card, the societal resources that promote or discourage use of the smart cards, and the influence of family and kin in nurturing decisions about use of the smart cards. We also used the cultural empowerment domain to investigate cultural beliefs and practices that are positive, cultural values and beliefs that are existential and have no harmful health consequences, and negative cultural beliefs or practices that affect utilization of the smart cards. The focus group discussions lasted between 60 and 75 min and discussions were audio-recorded with permission from participants. To preserve confidentiality during discussions, names or other identifiers were not used. The study was approved by the Institutional Review Board of the University of Nevada, Reno, and the Nigerian National Health Research Ethics Committee. All focus group discussion recordings were transcribed verbatim and analyzed thematically using framework analysis approach. Framework analysis is a systematic process for sifting, charting and sorting material according to key issues and themes [36]. This process involves data familiarization; identifying a thematic framework; indexing; charting; and mapping and interpretation [35–37, 41]. The research team began by reading the transcripts and field notes in its entirety to familiarize ourselves with the data. After reading the transcripts, four members of the research team collaboratively developed a coding frame. The coding frame was developed deductively by writing down recurring concepts and themes, while using the PEN-3 cultural model as a guide. Next, a list of open codes was sorted, relabeled and condensed into a smaller number of broad themes. This was followed by creating closed coding where codes related to the same theme were grouped together. Further, final codes and themes were discussed among the research team to reach a consensus. Two members of the research team independently applied the coding frame to the first transcript. The full research team then reviewed, discussed and resolved any inconsistencies before the coding of the rest of the transcripts. The main emerging themes were related to perceptions of mHealth, enablers for mHealth use and nurturers of mHealth use. These themes were further explored through a thorough review of each transcript. The final analysis framework was created to distinguish between positive, existential, and negative attributes related to the emerged themes – perceptions, enablers, and nurturers. The FGDs were conducted and analysed by members of the research team who have qualitative research skills. The processes were led by 2 members of the research team, one a physician with a Ph.D focused on health systems and qualitative research (CAO), the other holds a Ph.D in qualitative research and co-developed the PEN-3 cultural model (JI).
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