✪ When evidence is not enough: A qualitative exploration of healthcare workers’ perspectives on expansion of two-way texting (2wT) for post- circumcision follow-up in South Africa

Abstract:

As per South African national guidelines, in-person follow-up visits after voluntary medical male circumcision (VMMC) are required but may be unnecessary. Two-way texting (2wT), an mHealth platform, engages clients in post-operative care and triages those with complications to in-person review. 2wT was found to be safe, effective, and efficient. In South Africa, to understand provider perspectives on 2wT and potential for expansion, 20 key informant interviews were conducted with management, clinicians, data officials and support staff involved in 2wT scale-up. Interviews were analyzed using rapid qualitative methods and informed by two implementation science frameworks: the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework and the Pragmatic, Robust, Implementation and Sustainability Model (PRISM). Participants shared mixed and multi-faceted feedback, including that 2wT improves monitoring and evaluation of clients and clinical outcomes while also reducing follow-up visits. Challenges included duplicative routine and 2wT reporting systems and perceptions that 2wT increased workload. To improve the likelihood of successful 2wT scale-up in routine VMMC settings, participants suggested: further 2wT sensitization to ensure clinician and support staff buy-in; a dedicated clinician or nurse to manage telehealth clients; improved dashboards to better visualize 2wT client data; mobilizing 2wT champions at facilities to garner support for 2wT as routine care; and updating VMMC guidelines to support VMMC telehealth. As attendance at follow-up visits may not be as high as reported, implementing 2wT may require more effort but also brings added benefits of client verification and documented follow-up. The transition from research to routine practice is challenging, but use of RE-AIM and PRISM indicate that it is not impossible. As VMMC funding is decreasing, more effort to share the evidence base for 2wT as a safe, cost-effective, high-quality approach for VMMC follow-up is needed to encourage widespread uptake and adoption.

Author summary

South Africa has a high prevalence of HIV, and voluntary medical male circumcision is a prevention method recommended by the World Health Organization. Two-way texting (2wT) is a digital health intervention that allows males to receive educational messages after circumcision about healing and send messages directly to a provider via SMS or WhatsApp. This system detects as many complications as routine follow-up care, though is more efficient. As we scale up to new locations in South Africa, we wanted to ensure the approach is well-adapted for health workers. Through 20 interviews with health workers, we found that it saves clients in-person visits and helps with data collection. However, more effort is needed to introduce the intervention to clinicians, including providing better training and appointing champions to help motivate clinicians. Funding for HIV and VMMC programs is decreasing, so it is important to find tools such as digital health to reduce the burden on facilities while maintaining quality client care.

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