JMIR Publications

ABSTRACT

Background:

The expansion of cellular phones in sub-Saharan Africa spurred development of text-message (SMS) based mHealth technology. Numerous SMS-based interventions have attempted to increase retention in care for people living with HIV (PLWH) in sub-Saharan Africa. Despite promising pilot studies, many of these interventions have failed to scale, likely due to insufficient understanding of the factors that make novel SMS-based interventions acceptable to users. Understanding the theory-grounded factors leading to mHealth acceptability is needed to create scalable, contextually appropriate, user-focused interventions to improve longitudinal HIV care for PLWH in sub-Saharan Africa.

Objective:

To understand the relationship between constructs from the Unified Theory of Acceptance and Use of Technology (UTAUT), constructs identified in prior qualitative research, and behavioral intention to use a novel SMS-based mHealth intervention designed to improve care retention among PLWH initiating treatment in rural Uganda.

Methods:

We conducted a standardized survey of PLWH newly initiating in HIV care in Mbarara, Uganda, who had agreed to use a novel SMS-based system that notified them of abnormal lab results and reminded them to return to clinic. Survey items assessed behavioral intention to use the SMS system, constructs from UTAUT, and variables relating to demographics, literacy, SMS experience, HIV status disclosure, and social support. We used factor analysis and logistic regression to quantitatively estimate relationships between UTAUT constructs and behavioral intention to use the SMS system.

Results:

249 participants completed surveys, of whom 115 (46.2%) expressed high behavioral intention to use the SMS intervention. In a multivariable analysis, we found that performance expectancy (aOR of the scaled factor score: 5.69 [95%CI 2.64-12.25, P<0.001]), effort expectancy (aOR of the scaled factor score: 4.87 [95%CI 1.75-13.51, P=0.002]), and social influence (measured as a 1-unit Likert score increase in the perception that clinical staff have been helpful in the use of the SMS program) (aOR 3.03 [95%CI 1.21-7.54, P=0.02]) were significantly associated with high behavioral intention to use to the SMS program. SMS experience (aOR/1 unit increase 1.48 [95%CI 1.11-1.96, P=0.008]) and age (aOR/1 year increase 1.07 [95%CI 1.03-1.13, P=0.003]) were also significantly associated with increased odds of high intention to use the system.

Conclusions:

The UTAUT constructs of performance expectancy, effort expectancy, and social influence, as well as age and SMS experience, were key drivers of high behavioral intention to use an SMS reminder system among PLWH initiating treatment in rural Uganda. These findings point towards the salient theory-based factors associated with SMS intervention acceptability in this population, and indicate attributes that are likely key to successful development and scaling of novel mHealth interventions.