Participatory design approaches to develop global health interventions have gained traction in recent years. However, while broad frameworks for the application of design approaches exist, literature outlining concrete experiences of and guidance for navigating specific design challenges remains limited. This article proposes a design framework based on our own experiences when applying human-centered design principles to bolster sustainable hypertension medication financing in rural Uganda. In our case study, we embedded an mHealth platform within a community-led health intervention aiming to fund blood pressure medication through a shared financial pooling system. Over the course of this project and in close collaboration with intervention end-users, we developed a design framework that outlines challenges, decision-making processes, and design solutions. We iteratively refined the framework between November 2021 and April 2023 over two phases of extensive formative research and one phase of structured qualitative data collection, consisting of 55 in-depth interviews and 4 focus group discussions with clients with hypertension, health care providers, and key intervention stakeholders. The resulting MILEPOST framework consists of 7 domains to consider amid mHealth intervention co-development: medical (e.g., health challenge scope and management); interpersonal (e.g., communication, decision-making, and trust within and across communities); logistical (e.g., current processes and sustainable implementation pathways); ethical (e.g., research and implementation ethics); political (e.g., stakeholder buy-in and long-term support); scientific (e.g., rigorous and feasible approaches for data collection, management, and analysis); and technical (e.g., mHealth component development, refinement, and implementation). We define each domain, provide examples of design challenges and derived solutions as they emerged in our work, and outline starting points for operationalizing each domain in other contexts or studies. We discuss how MILEPOST can provide guidance to researchers and implementors by contributing specific and actionable insights for participatory health intervention design efforts.
BACKGROUND:HIV case management supports people living with HIV to be linked to and retained in care. HIV case management becomes virtual case management (VCM) when some or all these services are provided via virtual tools or platforms including mobile phones, chat messenger apps, other mobile or web apps, and/or electronic case management systems. The COVID-19 pandemic accelerated the use and expansion of virtual services, including health services, across the globe. PROGRAM DESCRIPTION:These case studies document how HIV programs in Indonesia and Nepal transitioned from in-person case management to VCM during the COVID-19 pandemic in 2020. As part of this transition, the program in Nepal implemented VCM in 37 districts that were providing services to 12,820 people living with HIV (PLHIV), and in Indonesia the program supported 18,244 PLHIV in 5 districts. Data on the transition from in-person support to VCM were collected on client clinical outcomes, costs of the virtual services, and case manager feedback. RESULTS:These case studies indicate that VCM is a feasible and affordable approach to implement in low- and middle-income country contexts. Between March and September 2020, 10,995 (82.1%) and 3,801 (51.5%) PLHIV in Nepal and Indonesia, respectively, were supported by VCM. Continuity of care remained high in both countries with only 1%-2% interruptions in treatment. Viral load suppression also remained high in both countries (91%-92% in Indonesia and 94%-95% in Nepal). Viral load coverage, however, was low, but this was influenced by clinic and laboratory closures. Startup costs were low (<US$2,500), and the monthly cost per person to provide VCM was $2.34 in Nepal and $4.67 in Indonesia. Case manager feedback was focused on compensation, expanded reach of virtual services, gaps in client mobile phone ownership or digital literacy, efficiency of services, and confidentiality and privacy. CONCLUSION:VCM has transformative potential to expand the reach of health services and provide differentiated options, meeting clients' preferences and needs. The experiences and lessons learned from these two case studies can guide the implementation of future VCM programs in other countries.
BACKGROUND:South African men have lower HIV testing uptake than their female counterparts, leading to lower antiretroviral treatment (ART) uptake and higher HIV-related mortality. A recent cluster-randomized trial in a high HIV prevalence area in Cape Town showed that relaying the "undetectable equals untransmittable" (U=U) message to South African men increased their HIV testing uptake compared to issuing standard testing invitations. We conducted an economic analysis based on this trial to inform decision-making regarding implementing U=U messaging in routine public-sector HIV care. METHODS:We analyzed the mean cost of the U=U intervention and its intermediate cost-effectiveness over the control arm. Costs were estimated from trial expenditure data in 2020 South African rand (ZAR), converted using March 2020 US$ exchange rates. Shared trial costs were allocated to each arm based on participant volume or days of operation; capital costs, including the creation of the U=U message via human-centered design workshops, were annualized over 8 years. In a second scenario, trial cost was adjusted for potential implementation in routine care. RESULTS:Peer promoters delivered 504 U=U invitations to test for HIV over 7 intervention days and 544 standard invitations over 5 control days in March 2020. Compared with standard invitations, men who received U=U messaging had 60% increased odds of getting tested for HIV. The average trial cost was $5.40 per U=U message delivered ($2.35 after adjustment for routine implementation), $388.47 per person testing HIV-positive ($168.99 adjusted), and $906.44 per person initiating ART ($394.31 adjusted). Within trial costs, staff, overhead, and research costs were the largest allocations, with each accounting for 20% to 30% of total costs. After routine implementation adjustment, the costs of message creation via human-centered design workshops, personnel (peer promoters, research staff), and supplies were the largest allocations. Cost of U=U messaging per person confirmed HIV-positive and initiating ART was lower than conventional HIV testing messaging and at the lower end of cost ranges of HIV self-test distribution models targeted at men ($62 to $7,936 per person confirmed positive and $117 to $8,198 per person initiating ART) established in previous work. CONCLUSION:Delivering tailored U=U messaging can increase HIV testing and ART uptake among men while saving costs over standard untargeted HIV testing messaging and other HIV self-test distribution models.
INTRODUCTION:Structural and service delivery barriers such as long waiting times, health care provider attitudes, and distance from services prevent access to HIV prevention and pre-exposure prophylaxis (PrEP) services, particularly for young people. The World Health Organization recommends differentiated service delivery models for HIV prevention and treatment services, including through mobile outreach. Mobile health clinics offer an opportunity to overcome barriers to service access by bringing services closer to places of work or study, improving convenience, minimizing stigma, and expanding the choice of service delivery locations and types. METHODS:We conducted a mixed-methods study describing a mobile service delivery model for HIV prevention and PrEP services in 3 provinces in South Africa. The study used routine program monitoring and evaluation data from 35,375 men and women aged ≥15 years accessing services at project fixed facility and mobile clinic sites between January 2019 and October 2022, in addition to data from 74 in-depth interviews with a purposively selected sample of adolescent girls and young women aged 15-24 years and men aged ≥15 years enrolled in a nested study cohort. RESULTS:Overall, 11,687 people were reached through mobile clinics between January 2019 and October 2022, of whom the majority were female (89.3%) and between 15-24 years (82.8%). Nearly all (96.0%) mobile clinic clients received an HIV test and 80.8% initiated oral PrEP, similar to HIV testing and PrEP initiation rates at the fixed facilities. Health care users demonstrated a high level of satisfaction with mobile health services, with benefits including a reduction in trips to fixed facilities, improved privacy, and reduced waiting times. However, some participants noted challenges with mobile services, including inconsistent schedules. CONCLUSION:Mobile health services with youth-friendly staff have the potential to reach young people in need of HIV prevention services and are feasible and acceptable in the South African setting. Mobile health services offered benefits such as convenience, privacy, and reduced need to travel to clinics, although they could be enhanced through improved consistency of services.
BACKGROUND:The health care system is a critical entry point for sexual violence response including care and linkages to auxiliary services. However, detailed data on quality and readiness of facility-based sexual violence care in African settings is sparse, hindering measurement and improvements. METHODS:We report results from the first wave of longitudinal mixed-methods study conducted between July and September 2022 to assess readiness and quality of sexual violence services in 4 counties in Kenya supported by the Accelerate program. Health facility assessments were conducted within all (N=123) program-supported facilities in the 4 counties, including provider interviews; visual inspection and audit of essential infrastructure and commodities; and chart abstraction. We computed descriptive data summaries, and in-depth interviews from 40 purposively selected providers were analyzed thematically. RESULTS:Of 123 study facilities, 54% had a provider who received GBV in-service training in the past 12 months. Most facilities (85%) routinely offered GBV care. Of facilities offering GBV care, most stocked antibiotic for sexually transmitted infections (STIs) (71%), any emergency contraception pill (ECP) option (88%), and tetanus vaccine (93%), and most provided GBV counseling (90%). However, availability of hepatitis B vaccine was low across facility tiers (14%-25%). Dispensaries/clinics documented low availability of HIV post-exposure prophylaxis (PEP) for children and adults (20% and 47%, respectively), SGBV register (20%), and post-rape care forms (27%). Of 285 abstracted charts, most were in hospitals (62%) and for survivors under 18 years (69%). Just 59% of survivors presented promptly, within 3 days, for health care services. Of survivors who were eligible for care, a considerable proportion missed psychosocial assessment (32%), PEP for HIV (22%), ECP (17%), and treatment for bacterial STIs (15%). Qualitative data revealed service delivery gaps driven by disruptions in supplies and provider capacity gaps. Many providers indicated concerns in the chain of evidence due to gaps in documentation and logistical support for health care providers when providing legal testimony in courts. CONCLUSIONS:Readiness to provide a minimum care package for sexual violence was low, with steep gradients across facility tiers. Delivery of timely and quality-assured sexual violence care requires addressing structural gaps driven by stock-out of supplies and inadequate providers' support including training. These corrective actions should be augmented by community-based interventions that link survivors to health care.
