“Endless Opportunities”: A Qualitative Study on Improving Two-Way Texting For Medical Male Circumcision Clients In Zimbabwe

Abstract

Background: Evidence shows that voluntary medical male circumcision (VMMC) as a one-time prevention method is a cost-effective way to reduce HIV transmission. In Zimbabwe, there is an HIV prevalence of 14.6% among adults, and health systems are strained due to healthcare worker (HCW) shortages. Digital health innovations, such as two-way texting (2wT), could help achieve the desired scale-up of VMMC programs and reduce HCW burden. 2wT-based, interactive follow-up was found to be cost-effective, beneficial to post-operative care, and positively perceived by both patients and HCWs. However, there have been some barriers in the transition from clinical trial to scale-up as part of routine care. To better understand the barriers to 2wT implementation as part of the larger VMMC national strategy, hearing directly from program partners about the challenges they are facing is essential.Methods: An exploratory qualitative study was conducted to identify the successes and challenges of the 2wT program in order to inform future scale-up efforts. Sixteen in-depth interviews were conducted with 2wT program partners that participated in the design, implementation, scale up, or maintenance of the ZAZIC Consortium’s 2wT program, including staff from within the Consortium, as well as program partner Medic, and Ministry of Health and Child Care site nurses. Partners were interviewed on the successes, challenges, and possible improvements of the 2wT program. A combination of inductive and deductive methods was used during data analysis which was conducted using ATLAS.ti. Results: Program partners who participated in this study largely felt that the successes of the 2wT program outweighed any challenges but shared potential ways that the program could be improved. Program successes included community buy-in, a strong foundational training, and usability of the 2wT app for both HCWs and clients. Factors identified that constrained program function and scale-up consisted of poor mobile network coverage, clients needing to buy airtime, and shortages of 2wT trained HCWs. Partners also discussed strategies to further improve the program, including exploring the optimal number of text messages, cascading the 2wT training, and updating the 2wT system to allow family members, especially youth, to register with the same phone number. Discussion: ZAZIC’s 2wT program highlights the importance of a community-driven approach throughout the various stages of implementation. Indeed, other mobile health studies found that partners who are able to provide numerous rounds of feedback may be more invested and engaged in health programs, something that could be linked with the high levels of 2wT community buy-in partners discussed. Furthermore, this study emphasizes the importance of an iterative process for optimization of care, and the need to adjust and adapt 2wT systems to specific contexts.