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

Abstract

Background Voluntary medical male circumcision (VMMC) is a safe and effective HIV prevention strategy. However, adherence to recommended in-person, postoperative follow-up is inefficient for procedures with few adverse events. Two-way texting (2wT)–based follow-up appears to be a safe and an efficient alternative to scheduled clinic visits for low-risk patients who underwent VMMC. To ensure that 2wT responds to the needs of health care workers (HCWs) and patients, HCWs were closely involved in app design using a human-centered design (HCD) approach. Objective Embedded within an ongoing randomized controlled trial of 2wT in South Africa and complementary HCD processes of 2wT app optimization, this qualitative study aimed to use key informant interviews (KIIs) to explore the thoughts, suggestions, and opinions on and perceptions of 2wT’s usability and acceptability among HCWs involved in 2wT implementation in both urban and rural South Africa. Methods A total of 7 HCWs using 2wT in Gauteng and the North West province participated in KIIs regarding the usability and acceptability of 2wT. HCWs were asked for their opinions on 2wT as a viable, useful, appropriate, and accessible method of postoperative VMMC care. They were also asked about 2wT-related working, exploring areas where 2wT could add to or reduce their daily tasks. The KII data were explored, coded, and analyzed by 3 qualitative researchers using thematic content analysis and the ATLAS.ti (ATLAS.ti Scientific Software Development GmbH) software. Results Most HCWs felt confident, comfortable, satisfied, and well supported using a 2wT-based follow-up as an alternative to in-person clinical reviews. They felt that 2wT was easy to use and required little technical support after initial mentoring on how to use the 2wT system. Few noted safety concerns, as men can receive clinical guidance, reassurance, and referral via 2wT. Although fewer in-person visits reduced the in-person review workload and eased clinical flow, HCWs noted the added burden of having to interact with clients via SMS text messages on evenings or weekends. HCWs reinforced the need for enhanced postoperative counseling to ensure that 2wT patients could recognize and understood how to respond to early signs of complications. HCWs suggested a rotation to spread the evening and weekend workload and ensure swift patient responses. Conclusions In this formative qualitative study focused on HCWs, 2wT was a highly usable alternative to in-person postoperative reviews for patients who underwent VMMC in South Africa. The HCD processes likely improved the usability and acceptability of 2wT for HCWs. HCWs supported the scale-up of 2wT given the distance from the clinic to the men’s homes and the potential for reducing workload. To ensure success, providers urged sensitizing patients to the fact that 2wT augments, but does not replace, the existing after-hours and emergency care services.

Expanding the Evidence on the Safety and Efficiency of 2-Way Text Messaging–Based Telehealth for Voluntary Medical Male Circumcision Follow-up Compared With In-Person Reviews: Randomized Controlled Trial in Rural and Urban South Africa

“…First, recent findings from usability testing among 2wT HCWs [ 79 ] showed that 2wT responded well to the expressed needs of HCWs and clients, increasing the likelihood of sustained use and widespread adoption [ 80 , 81 ]. From inception, 2wT adaptation, testing, and optimization processes adhered to the common principles for mHealth optimization focused on both patient and provider users, the engagement of broad stakeholders, providing training (and refresher training) to users via hands-on methods, using a simple technology with a familiar user interface, addressing a recognized need for updated VMMC policy, and using widely available SMS text messaging technology [ 82 ].…”

“Endless Opportunities”: A qualitative exploration of facilitators and barriers to scale-up of two-way texting follow-up after voluntary medical male circumcision in Zimbabwe

“…These lessons learned should be of great interest in South Africa where 2wT is scaling after evidence of safety, usability, and efficiency gains. [18][19][20] Interviewees noted that drivers of 2wT scale-up included enhanced promotion of client care and cost benefits, comprehensive and continuous HCW training, and ease of app use for HCWs and clients. In contrast, lack of available Second, as with other mHealth apps, 2wT enhanced provider to client communication and built relationships.…”

“…As men typically underutilize healthcare services, [41,42] mHealth appears to strengthen the relationships between male clients and their HCWs. [17,19] HCWs are aware that men may not be proactive seekers of healthcare services and want to better engage their male clients in care. [43] 2wT helped clinicians better care for their rural and distant clients by providing a platform for timely client/provider communication, [44] engaging clients and providers in a shared responsibility for healing.…”

“…[28] Moreover, users who are given multiple opportunities to provide feedback may be more invested and engaged in digital health programs, an important consideration as 2wT continues to generate multi-level buy-in for expansion. [14,19,29,30] User feedback is not a goal that can be accomplished, but rather a core component of frequent and flexible adjustment and adaptation to specific programmatic context. [19] Encouraging insights and feedback from HCWs, in particular, raises the likelihood of understanding what works in real-world clinical settings, aiding implementation success.…”

“…[14,19,29,30] User feedback is not a goal that can be accomplished, but rather a core component of frequent and flexible adjustment and adaptation to specific programmatic context. [19] Encouraging insights and feedback from HCWs, in particular, raises the likelihood of understanding what works in real-world clinical settings, aiding implementation success. [31] As 2wT has successfully been brought to scale and maintained for over 2 years in the Zimbabwe setting, there is a unique opportunity for inquiry to share with others in the growing mHealth field.…”