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BackgroundWireless electronic adherence monitors can detect antiretroviral therapy (ART) adherence lapses and trigger interventions in real time, thus potentially avoiding unnecessary HIV viremia. Evidence about the acceptability and feasibility of these monitors and associated interventions, however, is limited. ObjectiveThe aim of this study was to assess the acceptability and feasibility of real-time adherence monitoring linked to text messaging (short message service, SMS) reminders and notifications to support adherence among individuals living with HIV who are taking ART in rural southwestern Uganda. MethodsIndividuals living with HIV who were initiating ART were enrolled in a pilot randomized controlled trial and followed up for 9 months. Participants received a real-time adherence monitor and were randomized to one of the following study arms: (1) scheduled SMS, (2) SMS triggered by missed or delayed doses, or (3) no SMS. SMS notifications were also sent to 45 patient-identified social supporters for sustained adherence lapses in the scheduled SMS and triggered SMS arms. Study participants and social supporters participated in qualitative semistructured in-depth interviews on acceptability and feasibility of this technology. An inductive, content analytic approach, framed by the unified theory of acceptance and use of technology model, was used to analyze qualitative data. Quantitative feasibility data, including device functionality and SMS tracking data, were recorded based upon device metrics collected electronically and summarized descriptively. ResultsA total of 63 participants participated in the study. Participants reported that real-time monitoring intervention linked to SMS reminders and notifications are generally acceptable; the predominant feedback was perceived utility—the intervention was beneficial in motivating and reminding patients to take medication, as well as enabling provision of social support. ConclusionsReal-time adherence monitoring integrated with SMS reminders and social support notifications is a generally acceptable (based primarily on perceived utility) and feasible intervention in a resource-limited country. Future efforts should focus on optimized device design, user training to overcome the challenges we encountered, cost effectiveness studies, as well as studying the monitoring aspect of the device without accompanying interventions. Trial RegistrationClinicalTrials.gov NCT01957865; https://clinicaltrials.gov/ct2/show/NCT01957865 (Archived by WebCite at http://www.webcitation.org/6zFiDlXDa)

Background: Although there is an increasing use of digital adherence technologies (DATs), such as real-time monitors and SMS reminders in tuberculosis medication adherence, suboptimal patient engagement with various DATs has been reported. Additionally, financial constraints can limit DAT's utility. The perceived usefulness and the design mechanisms of DATs linked to mobile money financial incentives for tuberculosis medication management remain unclear., Objective: The aim of this study is to describe the perceived usefulness and design mechanisms for a DAT intervention called My Mobile Wallet, which is composed of real-time adherence monitors, SMS reminders, and mobile money incentives to support tuberculosis medication adherence in a low-income setting., Methods: This study used mixed methods approaches among persons with tuberculosis recruited from the Tuberculosis Clinic in the Mbarara Regional Referral Hospital. We purposively sampled 21 persons with tuberculosis aged 18 years and older, who owned cell phones and were able to use SMS text messaging interventions. We also enrolled 9 participants who used DATs in our previous study. We used focus group discussions with the 30 participants to solicit perceptions about the initial version of the My Mobile Wallet intervention, and then iteratively refined subsequent versions of the intervention following a user-centered design approach until the beta version of the intervention that suited their needs was developed. Surveys eliciting information about participants' cell phone use and perceptions of the intervention were also administered. Content analysis was used to inductively analyze qualitative data to derive categories describing the perceived usefulness of the intervention, concerns, and design mechanisms. Stata (version 13; StataCorp) was used to analyze survey data., Results: Participants expressed the perceived usefulness of the My Mobile Wallet intervention in terms of being reminded to take medication, supported with transport to the clinic, and money to meet other tuberculosis medication-related costs, all of which were perceived to imply care, which could create a sense of connectedness to health care workers. This could consequently cause participants to develop a self-perceived need to prove their commitment to adherence to health care workers who care for them, thereby motivating medication adherence. For fear of unintended tuberculosis status disclosure, 20 (67%) participants suggested using SMS language that is confidential-not easily related to tuberculosis. To reduce the possibilities of using the money for other competing demands, 25 (83%) participants preferred sending the money 1-2 days before the appointment to limit the time lag between receiving the money and visiting the clinic., Conclusions: DATs complemented with mobile money financial incentives could potentially provide acceptable approaches to remind, support, and motivate patients to adhere to taking their tuberculosis medication., Trial Registration: ClinicalTrials.gov NCT05656287; https://clinicaltrials.gov/ct2/show/NCT05656287., (©Angella Musiimenta, Wilson Tumuhimbise, Esther Atukunda, Aaron Mugaba, Sebastian Linnemayr, Jessica Haberer. Originally published in JMIR Formative Research (https://formative.jmir.org), 12.04.2023.)

Background: SMS text messaging and other mobile health (mHealth) interventions may improve knowledge transfer, strengthen access to social support (SS), and promote positive health behaviors among women in the perinatal period. However, few mHealth apps have been taken to scale in sub-Saharan Africa., Objective: We evaluated the feasibility, acceptability, and preliminary efficacy of a novel, mHealth-based, and patient-centered messaging app designed using behavioral science frameworks to promote maternity service use among pregnant women in Uganda., Methods: We performed a pilot randomized controlled trial between August 2020 and May 2021 at a referral hospital in Southwestern Uganda. We included 120 adult pregnant women enrolled in a 1:1:1 ratio to receive routine antenatal care (ANC; control), scheduled SMS text or audio messages from a novel messaging prototype (scheduled messaging [SM]), and SM plus SMS text messaging reminders to 2 participant-identified social supporters (SS). Participants completed face-to-face surveys at enrollment and in the postpartum period. The primary outcomes were feasibility and acceptability of the messaging prototype. Other outcomes included ANC attendance, skilled delivery, and SS. We conducted qualitative exit interviews with 15 women from each intervention arm to explore the intervention mechanisms. Quantitative and qualitative data were analyzed using STATA and NVivo, respectively., Results: More than 85% and 75% of participants received ≥85% of the intended SMS text messages or voice calls, respectively. More than 85% of the intended messages were received within 1 hour of the expected time; 18% (7/40) of women experienced network issues for both intervention groups. Over 90% (36/40) of the intervention participants found this app useful, easy to use, engaging, and compatible and strongly recommended it to others; 70% (28/40), 78% (31/40), and 98% (39/40; P=.04) of women in the control, SM, and SS arms, respectively, had a skilled delivery. Half (20/40), 83% (33/40), and all (40/40; P=.001) of the women in the control, SM, and SS arms attended ≥4 ANC visits, respectively. Women in the SS arm reported the highest support (median 3.4, IQR 2.8-3.6; P=.02); <20% (8/40; P=.002) missed any scheduled ANC visit owing to lack of transportation. Qualitative data showed that women liked the app; they were able to comprehend ANC and skilled delivery benefits and easily share and discuss tailored information with their significant others, who in turn committed to providing them the needed support to prepare and seek help., Conclusions: We demonstrated that developing a novel patient-centered and tailored messaging app that leverages SS networks and relationships is a feasible, acceptable, and useful approach to communicate important targeted health-related information and support pregnant women in rural Southwestern Uganda to use available maternity care services. Further evaluation of maternal-fetal outcomes and integration of this intervention into routine care is needed., Trial Registration: ClinicalTrials.gov NCT04313348; https://clinicaltrials.gov/ct2/show/NCT04313348., (©Esther C Atukunda, Mark J Siedner, Celestino Obua, Angella Musiimenta, Norma C Ware, Samuel Mugisha, Josephine N Najjuma, Godfrey R Mugyenyi, Lynn T Matthews. Originally published in JMIR Formative Research (https://formative.jmir.org), 02.03.2023.)

Background: Antenatal care (ANC) prevents perinatal morbidity and mortality, but use of these services in Uganda remains low and maternal mortality rates are among the highest in the world. There is growing evidence that mobile health (mHealth) approaches improve timely communication of health-related information and produce positive health behavior change as well as health outcomes. However, there are limited data to guide development of such interventions in settings where ANC attendance and uptake of skilled maternity care are low., Objective: The aim of this study is to develop a novel patient-centered mHealth intervention to encourage and support women to use maternity care services in Mbarara district, southwestern Uganda., Methods: Using an iterative development approach, we conducted formative stakeholder interviews with 30 women and 5 health care providers (HCPs) to identify preferred key ANC topics and characterize the preferred messaging intervention; developed content for SMS text messaging and audio messaging with the help of 4 medical experts based on the identified topics; designed an app prototype through partnership with an mHealth development company; and pilot-tested the prototype and sought user experiences and feedback to refine the intervention through 3 sets of iterative interviews, a focus group discussion, and 5 cognitive interviews. Qualitative data were coded and analyzed using NVivo (version 12.0; QSR International)., Results: Of the 75 women who completed interviews during the development of the prototype, 39 (52%) had at least a primary education and 75 (100%) had access to a mobile phone. The formative interviews identified 20 preferred perinatal health topics, ranging from native medicine use to comorbid disorders and danger signs during pregnancy. In all, 6 additional topics were identified by the interviewed HCPs, including birth preparedness, skilled delivery, male partner's involvement, HCP interaction, immunization, and caring for the baby. Positive audio messaging and SMS text messaging content without authoritative tones was developed as characterized by the interviewed women. The postpilot iterative interviews and focus group discussion revealed a preference for customized messaging, reflecting an individual need to be included and connected. The women preferred short, concise, clear actionable messages that guided, supported, and motivated them to keep alert and seek professional help. Complementary weekly reminders to the women's significant others were also preferred to encourage continuity or prompt the needed social support for care seeking., Conclusions: We used an iterative approach with diffuse stakeholders to develop a patient-centered audio messaging and SMS text messaging app designed to communicate important targeted health-related information and support rural pregnant women in southwestern Uganda. Involving both HCPs and end users in developing and formulating the mHealth intervention allowed us to tailor the intervention characteristics to the women's preferences. Future work will address the feasibility, acceptability, and effectiveness of this design approach., (©Esther Cathyln Atukunda, Lynn T Matthews, Angella Musiimenta, Godfrey Rwambuka Mugyenyi, Samuel Mugisha, Norma C Ware, Celestino Obua, Mark J Siedner. Originally published in JMIR Formative Research (https://formative.jmir.org), 25.11.2021.)

Background: Reducing maternal and infant mortality rates remains challenging. Illiteracy, lack of reliable information, long distances to health centers continue to limit access to quality maternal healthcare in Uganda. Mobile health technologies could be promising affordable strategies for enhancing access to maternal health services. However, there is lack of studies assessing the experiences of illiterate rural pregnant women regarding these technologies. Objective: To explore how illiterate pregnant women perceive a maternal health mobile application composed of tailored video and audio messages, appointment reminders and calling function. Methods: We purposively sampled illiterate pregnant women initiating antenatal care at Mbarara Regional Referral Hospital. We carried out three focus group discussions with 14 women to elicit information on perceptions of the proposed mobile phone based multimedia application. We used STATA 13 to describe study participants and their preferences. Results: Pregnant women anticipated that intervention would enhance maternal health by reminding them to attend antenatal appointments, enabling transport cost and time saving, providing tailored information that is easy to understand, and recall. However, financial constraints and phone sharing would limit the functionality. Conclusion: Mhealth application may provide acceptable and affordable alternative approaches to providing maternal health services, especially in settings where face-to-face approaches are challenging., (This is an Open Access article. Authors own copyright of their articles appearing in the Journal of Public Health Informatics. Readers may copy articles without permission of the copyright owner(s), as long as the author and OJPHI are acknowledged in the copy and the copy is used for educational, not-for-profit purposes.)

Objective: School-based sexual health education interventions can reach young people of diverse backgrounds and equip them with knowledge and skills for protecting themselves against HIV/AIDS, unwanted pregnancies, and live healthy and responsible lives. However, given that school-based sexual health education intervention are health projects implemented in educational settings, variety of social and institutional issues can present challenges. This study aimed to obtain rich insights into the facilitating or inhibiting mediators for the implementation of a school-based sexual health education intervention in Uganda., Method: This study conducted 16 qualitative interviews to investigate the mediators for the implementation of the school-based sexual health education intervention based on experiences of two Ugandan schools: the school which successfully completed the implementation of the intervention, and the school which abandoned the intervention half-way the implementation., Results: Rather than the technological aspects, results indicate that the implementation was strongly influenced by interplay of social and institutional mediators, which were more favourable in the "successful" school than in the "failure school". These mediators were: perceived students' vulnerability to HIV and unwanted pregnancies; teachers' skills and willingness to deliver the intervention, management support; match with routine workflow, social-cultural and religious compatibility, and stakeholder involvement., Conclusion: Rather than focusing exclusively on technological aspects, experiences from this evaluation suggest the urgent need to also create social, institutional, and religious climate which are supportive of school-based computer-assisted sexual health education. Evidence-based recommendations are provided, which can guide potential replications, improvements, and policy formulation in subsequent school-based sexual health education interventions.

Background: Although Uganda had recorded declines in HIV infection rates around 1990's, it is argued that HIV/AIDS risk sexual behaviour, especially among the youth, started increasing again from early 2000. School-based computer-assisted HIV interventions can provide interactive ways of improving the youth's HIV knowledge, attitudes and skills. However, these interventions have long been reported to have limited success in improving the youth's sexual behaviours, which is always the major aim of implementing such interventions. This could be because the commonly used health promotion theories employed by these interventions have limited application in HIV prevention. These theories tend to lack sufficient attention to contextual mediators that influence ones sexual behaviours. Moreover, literature increasingly expresses dissatisfaction with the dominant prevailing descriptive survey-type HIV/AIDS-related research., Objective and Methods: The objective of this research was to identify contextual mediators that influence the youth's decision to adopt and maintain the HIV/AIDS preventive behaviour advocated by a computer-assisted intervention. To achieve this objective, this research employed qualitative method, which provided in-depth understanding of how different contexts interact to influence the effectiveness of HIV/AIDS interventions. The research question was: What contextual mediators are influencing the youth's decision to adopt and maintain the HIV/AIDS preventive behaviour advocated by a computer-assisted intervention? To answer this research question, 20 youth who had previously completed the WSWM intervention when they were still in secondary schools were telephone interviewed between Sept.08 and Dec.08. The collected data was then analysed, based on grounded theory's coding scheme., Results: Findings demonstrate that although often ignored by HIV interventionists and researchers, variety of contextual mediators influence individual uptake of HIV preventives. These include relationship characteristics, familial mediators, peer influence, gender-based social norms, economic factors and religious beliefs., Conclusion: To generate concomitant mutual efforts, rather than exclusively focusing on individual level mediators, there is an urgent need to shift to integrative approaches, which combine individual level change strategies with contextual level change approaches in the design and implementation of interventional strategies to fight against HIV/AIDS.

Unlike traditional approaches to sexuality and HIV education which can be constrained by the sensitive nature of the subject, Information Technology (IT) can be an innovative teaching tool that can be used to educate people about HIV. This is especially relevant to interventions targeting young people; the population group fond of using IT, and the same group that is more vulnerable to HIV/AIDS. Yet, there are significantly few empirical studies that rigorously evaluated computer-assisted school-based HIV/AIDS interventions in developing countries. The modest studies conducted in this area have largely been conducted in developed countries, leaving little known about the effectiveness of such interventions in low resource settings, which moreover host the majority of HIV/AIDS infections. This research addresses this gap by conducting a controlled pre-post intervention evaluation of the impacts of the World Starts With Me (WSWM), a computer-assisted HIV/AIDS intervention implemented in schools in Uganda. The research question was: did the WSWM intervention significantly influence students' sexual behaviors, HIV/AIDS knowledge, attitudes and self-efficacy? To address this question, questionnaires were simultaneously administering to 146 students in an intervention group (the group receiving the WSWM intervention) and 146 students in a comparison group (the group who did not receive the WSWM intervention), before (February 2009) and after the intervention (December 2009). Findings indicate that the intervention significantly improved students' HIV/AIDS knowledge, attitudes self-efficacy, sex abstinence and fidelity, but had no significant impact on condom use. The major reason for non-use of condoms was lack of knowledge about condom use which can be attributed to teachers' failure and inabilities to demonstrate condom use in class. To address this challenge, intervention teachers should be continuously trained in skills-based and interactive sexuality education. This training will equip them with self-confidence and interactive teaching skills, including tactics for emphasizing building students' skills through role plays and interactive assignments. In addition, the HIV interventions themselves should include interactive virtual condom use demonstrations that can be accessed by students themselves.