Testing understanding of the messages
Dose reminders Only dose-two reminders were discussed since all dose reminders had the same content, except for the dose number. Two messages were discussed in this category:
Message 1
Hello Maorine Aoko Ojwang, have you remembered to give your child the 2nd dose of AL? If not, please do so. Thank you, Doctor Bondo District hospital.
Message 2
Hello Maorine Aoko Ojwang, please remember to give your child the 2nd dose of AL. Thank you, Doctor Bondo District hospital.
The abbreviation “AL” in the two messages was not familiar to most caregivers.
“My worry is, not all of us know about the drugs so this AL, let’s say you have sent me this message and I don’t know what AL is, I will be confused.” [FGD, English].
Participants were concerned that most caregivers would not know the name of the drug they had been given.
“I still refuse this coartem, [name suggested to replace AL] for one reason, there are some ‘shoshos’ [grandmothers] at home but if you send the coartem, they will not read that coartem, but if you send anti malaria, the shosho will remember yes, my granddaughter sick with malaria so I think this is the same drug they are referring to.” [FGD, English].
Participants agreed to use a more general term ‘malaria medicine’ as opposed to specific drug names. Some participants also expressed concerns that message two could lead to overdose if the caregiver received the message after they had already given the required dose.
“Yeah, with the first one, [message one] the doctor first confirmed with me if I have already given [the dose] or not, then he urged me to do so if I had not done it. But this one [the second message] is reminding me to remember. Suppose I had given the baby the dose the medicine… So I don’t know whether to give so, I might give the second dose when I have already given… I prefer the first one because the person has asked the person if the person has already given the drug and if not please do so.” [FGD, English].
In addition, message one was perceived to be more forceful as it asks a question “have you…?” and directs an action “If not, please do so” if the caregiver had forgotten to dose their child.
“Me, I see the second one doesn’t the person a lot, when you read it, it does not have that seriousness, like me I have got it and took it just like that, because it is requesting me, but when you read the first one, Have you? It is like asking you a question, it is a question to me, it is attacking me direct.” [FGD, Kiswahili].
Given the preference for message one and concerns raised about possibility of confusing the caregiver if a specified dose had already been given before receiving the message, message one was adopted with an amendment replacing “AL” with “malaria medicine” as suggested by the groups (Table
4).
Table 4
SMS messages adopted following the focus group discussions
AL dose reminders | Hello [name of care giver], have you remembered to give your child the [dose number] dose of malaria medicine? If not, please do so. Thank you, [Name of health facility] |
Day 3 post-treatment review reminder |
Evening | Hello [name of care giver], please remember to bring the child back to hospital tomorrow to confirm clearance of malaria parasites. Thank you, [Name of health facility] |
Morning | Hello [name of care giver], please remember to bring the child back to hospital today to confirm clearance of malaria parasites. Thank you, [Name of health facility] |
Unscheduled visit prompt | Hello [name of care giver] I hope the child is doing well. If not, please bring them back to the hospital as soon as possible. Thank you, [Name of health facility]. |
Day 28 post-treatment review reminder | Hello [name of care giver], please bring your child back to the hospital tomorrow for day 28 review as advised by the doctor. Thank you, [Name of health facility] |
Hello [name of care giver], please bring your child back to the hospital today for day 28 review as advised by the doctor. Thank you, [Name of health facility] |
Day three post-treatment review reminders Four messages were discussed:
Message 1
Hello Mary Akinyi Bukhula, please remember to bring your child back to the hospital tomorrow for review. This is important to check if the child is free from malaria. Thank you, Doctor Bondo District hospital.
Messages 2
Hello Mama Junior, thank you for finishing malaria treatment for Junior, please remember to bring back the child for review tomorrow as we had agreed. Thank you, Got Agulu SDH.
Message 3
Hello Michael Ojwang, thank you for giving AL dose to your child as advised by the doctor, please bring your child back to the hospital tomorrow to confirm if the malaria parasites have cleared. Sister Ndori Health Centre.
Message 4
Hello Mary, please bring your child to Ndori Health Centre for review tomorrow to check if the child is free from malaria. Thank you, Sister Ndori.
Participants raised concerns about the assumptions made in messages two and three.
[Referring to message two] “The doctor is assuming that you had finished the dose that you were given… but there is a problem, why? Most mothers we do assume or negligence or I don’t know how to call it but once you see the child now can play, can laugh, even if you get the message you will not go you assume that the child is now okay.” [FGD, English].
There were also concerns about how messages three and four were signed off. Many of the participants preferred to use the health facility name instead of health care provider citing poor relationship between caregivers and individual health care providers.
[Message three] “Some health workers are always very arrogant until maybe they make the mother feel very bad to go back to the facility for treatment because they know sister so and so is there she will treat me the same way she treated me the other day, so this always, there is stigma for most mothers they don’t go back to the facility because of that.” [FGD, English].
[Message four] “Write full name, one can go to the wrong hospital…Hospital is more important than saying sister, sister Ndori, say Ndori Hospital.” [FGD, Kiswahili].
Participants also expressed a preference for messages that addressed the caregiver by their specific name rather than in general terms, such as ‘mama’.
“The first [message one] is better, it indicates the name Akinyi. Mama Junior could be many, if you ask for mama Junior, it is not specific.” [FGD, Dholuo].
There was general consensus that stating the purpose of the visit added weight to the message and the mention of “malaria parasites” in message three was felt to reinforce the need to take the child for review:
[Referring to message three] “He [the doctor] wants to confirm if malaria is finished in the child, that’s why he wants you to take the child back, he wants to follow up…they have told you the importance of taking the child back…the other one [referring to message two] was open, it was just telling us to take the child back but maybe others will wonder why take the child back, I have finished the dose, but this one is telling us the why…we are going to confirm that malaria parasites are finished.” [FGD, English].
Taking into consideration all issues raised by the groups, the final message combined the first part of message one: (Hello Mary Akinyi Bukhula, please remember to bring your child back to the hospital tomorrow) and the second part of message three: (to confirm if the malaria parasites have cleared). Since the message was to be sent in the evening of day 2 and morning of day 3, the word “tomorrow” was replaced with “today” in the morning message. Following concerns raised regarding signing off the messages with “sister”, it was decided to sign off all messages with the name of the health facility only (Table
4).
Unscheduled visit prompts
Message 1
Hello Mary Akinyi Bukhula, I hope the child is well. If not, please bring the child back to the hospital for review. Thank you, Doctor Bondo District hospital.
Message 2
Hello Mama Junior, I hope your child is doing well. If not, please bring the child the back to the hospital immediately. Thank you, sister Got Agulu SDH.
The key concern about these messages was the use of the term “immediately” in message two. Many of the participants felt this was demanding and unrealistic, citing lack of transport especially at night and the fact that health facilities are not open 24 h, 7 days a week.
“Comment, comment here is immediately, by immediately, let’s say the child was sick last night, when you say immediately, will you attend to the client even at night?” [FGD, English].
However some caregivers thought the use of the word “immediately” conveyed a sense of urgency and added weight to the message;
“Okay to me the way I understand it, this term immediately, it shows that emergency, you when I as a mother, I will read this message and read immediately. …to me I see there is some emergency on it, so I will rush to the hospital … I think this word immediately will help a lot because if the mother if the child is still sick, the mother will say ah, I will go tomorrow. The child is becoming weak, let me give this child panadol, then I finish my work, then I will go tomorrow again. The child is still weak, now this immediately will help a lot”.
Since the two messages were very similar in content and the only contention was the practicality of bringing the child to the facility “immediately”, the term was replaced with “as soon as possible”.
Day 28 post-treatment review reminder
Message 1
Hello Mary Akinyi Bukhula, please remember to bring your child again tomorrow to hospital for reassessment. Thank you, Doctor Bondo District hospital.
Message 2
Hello Mama Junior, please remember to bring your child back to hospital tomorrow as we agreed, Sister Got Agulu SDH.
The term “reassessment” in message one was not clear to the participants and they suggested the addition of the term “malaria” to remind the caregiver what was being reassessed.
“To me, I see that reassessment is not so open…me I see is like you should stress that reassessment at least to give it a little weight … “Me I see this one is still hanging…you could have added something.” [FGD, Kiswahili].
In addition, several participants suggested that a mention of “day 28” should be added to the message to help the caregiver recall about the advice given to return the child on day 28. Message two was felt to contain connotations in the expression “as we agreed” that could negatively affect the caregiver.
“My husband will wonder if the doctor says ‘as we had agreed’. It can be misinterpreted” [FGD, Dholuo].
Consequently the expression “as we agreed” was rephrased to “as advised by the doctor” and a reference to “day 28” was added to the message (Table
4).
Following the FGDs, ten messages were adopted from each language: five dose reminders each specifying the dose number; two (morning and evening) day 3 post-treatment review visit reminders; one unscheduled visit prompt; and, two (morning and evening) day 28 review reminders. To check consistency across the three languages, a native speaker of Dholuo and a Kiswahili language expert back-translated the messages into English. A member of the research team (SG) compared back-translated messages with the ones developed in English and ascertained that the content and meaning was identical across the three languages.
Piloting and refinement of the automated distribution system
Only 169 out of 240 (70%) scheduled messages were delivered to the piloted caregivers. None of the caregivers in the pilot received all the 12 scheduled messages. Fourteen of the 20 caregivers piloted received reminders for dose 2, 3 and 5; 18 received dose four reminder and 19 received reminder for dose 6. While all piloted caregivers received day 3 post-treatment review reminders, only five of them received all the scheduled dose reminders. The weekly unscheduled visit prompts for day 7, 14 and 21 were received by 12, 14 and 15 caregivers, respectively. Day 28 evening and morning reminders were received by 19 and 17 caregivers, respectively. Only eight caregivers received all unscheduled visit prompts and day 28 review visit reminders. Eighteen of the 20 caregivers piloted read the messages by themselves and correctly interpreted their meaning. Two caregivers had the messages read and interpreted for them correctly by another member of their household.
A meeting was held between the research team and the system programmers to discuss the pilot outcome. Poor Internet connectivity affecting transmission of scheduled messages from the web-based system to the in-built gateway and bugs within the system were established as the main reasons leading to the low reception of the messages during the pilot. Connectivity was resolved by relocating the gateway to a server room with reliable Internet. Bugs within the system were identified by continuously testing, troubleshooting and monitoring of the system. Over 100 healthy volunteers were repeatedly registered into the system over a period of 3 months and followed up to ascertain whether they received each message as scheduled. The research team notified the system developers of any messages that were delayed or not sent. The developers checked the system to troubleshoot and fix the errors. This process was continued until the system consistently sent all the messages to each registered volunteer as per the established schedule. Finally, to improve on system monitoring, an application was added to the system to send SMS notifications to the research team whenever there was a failure in the system.