Centering healthcare workers in developing digital health interventions: usability and acceptability of a two-way texting retention intervention in a public HIV clinic in Lilongwe, Malawi

BackgroundNew initiates on antiretroviral therapy (ART) are at high risk of treatment discontinuation, putting their health at risk. In low-resource settings, like Malawi, appropriate digital health applications must fit into local connectivity and resource constraints. Target users perspectives are critical for app usability, buy-in and optimization. We describe the formative stages of the design of a two-way text-based (2wT) system of tailored reminders and adherence messages for new ART initiates and share results from key informant interviews with HCWs focused on app usability and acceptability. MethodsUsing a co-creation approach with clients, clinical, technical and evaluation teams and over app development, we held four informal user feedback sessions, a small pilot with 50 clients, and ten key informant (KIIs) to deepen our understanding of healthcare workers (HCWs) needs, acceptability and usability. ResultsFormative research informed the design of interactive client-to-HCW communication, refining of the language and timing of weekly text blast motivational messages and tailored client-specific visit reminders. Informal feedback from HCW stakeholders also informed educational materials to enhance 2wT client understanding of how to report transfers, request visit date changes and ask questions related to their visits. In KII, HCWs noted their appreciation for the co-creation process, believing that the participatory HCD process and responsive design team enabled the development of a highly acceptable and usable 2wT digital tool. HCWs also suggested future improvements to promote inclusion of clients of varying literacy levels and economic backgrounds as well as integrating with other health platforms to improve uptake of 2wT. ConclusionsInclusion of HCWs increased perceptions of app usability and acceptability among HCWs. HCWs believe that 2wT will improve on-time ART visit attendance and provide valuable early retention in care support. The co-creation approach appears successful in designing an app that will meet HCW needs and, therefore, support client adherence to visits. Author SummaryPeople starting antiretroviral treatment (ART) are at risk of poor or non-adherence which could lead to treatment failure or drug resistance, putting their health at risk. To help improve client adherence and, therefore, client outcomes, healthcare workers and healthcare systems need user-centred digital innovations that are appropriate for low- resource settings. Using a co-creation approach between the clients, clinical, technical, and evaluation teams, we designed, developed, and optimized a two-way text-based (2wT) system of tailored reminders and motivation messages for new ART initiates at Lighthouse Trusts public ART clinic in Lilongwe, Malawi. The application leveraged the open-source, Community Health Toolkit, and was designed based on evidence of previous 2wT success in client engagement. We describe the formative stages of app co-design and share results from key informant interviews with HCWs focused on app usability and acceptability. We detail findings on the 2wT system design, perceived strengths, weaknesses, and recommendations for improvement to inform continued optimization for scale up. Overall, the co-creation approach appears successful in designing an app that will meet HCW needs and, therefore, support client adherence to visits.