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

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.

The effect of proactive, interactive, two-way texting on 12-month retention in antiretroviral therapy: findings from a quasi-experimental study in Lilongwe, Malawi

“…For participants, the 2wT approach was perceived as user-friendly, responses were easy, and both motivational and visit reminders were appreciated [42]. For HCWs, 2wT was highly usable and was perceived to improve their connection with participants, reflecting their needs [55]. Lighthouse HCWs currently maintain the day-to-day operations and management of the 2wT system independently, factors that enhance the likelihood of sustaining the intervention [58].…”

“…The 2wT approach was developed in accordance with the Principles for Digital Development [53] and based on the open-source Community Health Toolkit (CHT) [54]. 2wT’s easy-to-use CHT-based design resulted from an iterative human-centered design (HCD) process that incorporated feedback from LT clients, HCWs, and retention officers, described previously [55]. In brief, 2wT is a free, proactive, mHealth intervention that combines automated motivation messages with interactive individualized visit reminders ( Fig 2) [42].…”

Cost-effectiveness analysis of two-way texting (2wT) intervention to improve ART retention among newly-initiated antiretroviral therapy clients in Malawi

“…The 2wT is also free, thereby encouraging client feedback. Additionally, the 2wT intervention is also beneficial to the healthcare facility by helping HCWs streamline their workload by reducing unnecessary tracing and automating the generation of defaulter lists, which can lead to improved efficiency and resource allocation within the healthcare system [37].…”

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

“…Web-based messaging, such as 2wT, has been proven to be effective in influencing HIV-related behaviors [ 26 , 27 ]. Furthermore, 2wT has been tested in other contexts in the countries in the African continent, including Zimbabwe [ 16 - 19 ] and Malawi [ 28 , 29 ]. In these contexts, HCWs found that 2wT was highly usable [ 17 , 28 , 29 ], encouraged clients to proactively engage with the healing process [ 17 ], was safe, was inexpensive, and had value [ 28 , 29 ].…”

“…Furthermore, 2wT has been tested in other contexts in the countries in the African continent, including Zimbabwe [16][17][18][19] and Malawi [28,29]. In these contexts, HCWs found that 2wT was highly usable [17,28,29], encouraged clients to proactively engage with the healing process [17], was safe, was inexpensive, and had value [28,29]. However, the application of behavior theory can help guide the understanding of usability and acceptability to ensure optimization for each new adaptation or context.…”