JMIR Publications

ABSTRACT

Background:

Telehealth is growing as a way to communicate, especially in areas where access to health facilities is difficult. We previously employed two-way texting (2wT) via SMS to improve the quality of post-operative care after voluntary medical male circumcision (VMMC) in South Africa. SMS was employed as costs can be covered by the service provider and require only basic, feature phones.

Objective:

In this process evaluation embedded within a larger 2wT expansion trial, our objectives were: 1) to explore 2wT client preferences, including client satisfaction, with WhatsApp for SMS or WhatsApp; 2) to examine response rates (participation) by SMS and WhatsApp; and 3) gather feedback from the 2wT implementation team on the WhatsApp approach for 2wT. We apply an implementation science lens using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance)1 framework to focus results on practice and policy improvement.

Methods:

Males ages 15 and older undergoing VMMC in program sites could choose between SMS or WhatsApp for 2wT-based follow-up. We analyzed quantitative data from the 2wT database on message delivery platform (WhatsApp vs SMS), response rates, and message content. The team conducted short phone calls with WhatsApp clients about their perceptions of this 2wT platform using a short, structured interview guide. We consider informal reflections from the technical team members on the use of WhatsApp.

Results:

Over a 2-month period, from August - October, 2023, 363 males enrolled in 2wT and were offered WhatsApp or SMS. For 2wT reach, 53% of participants chose WhatsApp as their platform. The overall mean age was 30 and 75% of participants chose English for automated messages. Almost all (98%) males were pleased with their 2wT platform choice. For effectiveness, response rates were similar: 23 vs 20% for WhatsApp and SMS users responded. For implementation, 2wT study team members noted that they believed WhatsApp limited the automated message content, language choices, and inclusivity as compared to the SMS-based 2wT approach.

Conclusions:

When presented with a choice of communication platform, clients appear to split between SMS and WhatsApp for this 2wT approach. However, WhatsApp requires a smartphone and data plan, potentially reducing reach. Clients using either WhatsApp or SMS responded to 2wT interactive prompts, demonstrating similar effectiveness in engaging clients in follow-up. However, for this 2wT intervention, WhatsApp implementation limitations still prevent considerable barriers for telehealth. Digital health designers and implementors should consider communication platforms that reflect a choice for both SMS and WhatsApp but must be weight potential advantages with the disadvantages to determine their best implementation approach. Clinical Trial: Research reported in this publication was supported by the National Institute of Nursing Research of the NIH under award number 5R01NR019229 (“Expanding and Scaling Two-way Texting to Reduce Unnecessary Follow-Up and Improve Adverse Event Identification Among Voluntary Medical Male Circumcision Clients in the Republic of South Africa”).