Conducting a Rapid Assessment of MomConnect Project from ... · Natal Department of Health and UNICEF by Virtual Purple Health Systems (VP) and the Praekelt ... The South African

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Conducting a Rapid Assessment of MomConnect Project from September 2011 to date in eThekwini and Umgungundlovu districts, KwaZulu-Natal

3 August 2016

UNICEF to advise on additional branding required.

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Contents Acknowledgements ................................................................................................................................. 3

Acronyms and abbreviations .................................................................................................................. 4

Executive Summary ................................................................................................................................. 5

1 Introduction .................................................................................................................................... 8

1.1 Background ............................................................................................................................. 8

1.2 South African mHealth interventions for PMTCT ................................................................... 9

1.3 MomConnect project design................................................................................................. 10

2 Project Timeline ............................................................................................................................ 12

3 Evaluation methodology ............................................................................................................... 13

3.1 Overview of study design ...................................................................................................... 13

3.2 Eligibility criteria.................................................................................................................... 15

3.3 Recruitment of clients and healthcare workers.................................................................... 15

3.4 Data collection and analysis .................................................................................................. 17

3.5 Research ethics ..................................................................................................................... 17

4 Results ........................................................................................................................................... 18

4.1 Quantitative findings............................................................................................................. 18

4.2 Qualitative findings – clients ................................................................................................. 23

4.3 Qualitative findings – healthcare workers ............................................................................ 26

5 Discussion ...................................................................................................................................... 28

6 Limitations..................................................................................................................................... 29

7 Recommendations ........................................................................................................................ 30

8 Conclusion ..................................................................................................................................... 31

References ............................................................................................................................................ 32

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Acknowledgements The authors would like to acknowledge the support, guidance and input of Otty Mhlongo from the KwaZulu-Natal Department of Health and Sanjana Bhardwaj and Kondwani N’goma from UNICEF. The authors are also grateful to the healthcare workers and clients for agreeing to participate in the evaluation and for giving up their time. The hard work of the field worker team is also acknowledged. Thanks to Virtual Purple Health Systems (Warren Lambert, Shaun Krog and Silindile Mnembe) and Praekelt Health (Matthew de Gale) for sharing documents and responding to queries. Nikhat Hoosen conducted the literature review, ethics submission and provided project support. Catherine Searle, Kevi Naidu and Arthi Ramkissoon are funded by PEPFAR (United States President’s Emergency Plan for AIDS Relief). The contents of this report are the sole responsibility of MatCH (Maternal, Adolescent and Child Health Systems) and do not necessarily reflect the views of USAID (United States’ Agency for International Development) or the United States Government.

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Acronyms and abbreviations ANC Antenatal care

ARV Antiretroviral

ART Antiretroviral therapy

AZT Azidothymidine

DHIS District Health Information System

eHealth Electronic Health

HIV Human Immunodeficiency Virus

ICT Information and Communications Technology

IePRS Integrated Electronic Patient Record System

KZN KwaZulu-Natal

mHealth Use of mobile phones and other wireless technology in medical care

MatCH Maternal, Adolescent and Child Health Systems

PCR Polymerase chain reaction

PEPFAR United States’ President’s Emergency Plan for AIDS Relief

PMTCT Prevention of Mother-To-Child Transmission

SMS Short Message Service and name given to text message sent on mobile phone

TB Tuberculosis

UNICEF United Nations Children’s Emergency Fund

USAID United States’ Agency for International Development

USSD Unstructured Supplementary Service Data

VEMR Virtual Electronic Medical Record System

VP Virtual Purple Health Systems

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Executive Summary

Background This report summarises key findings from a rapid evaluation of the KwaZulu-Natal Department of Health’s pilot mHealth project, MomConnect, implemented in eThekwini and Umgungundlovu districts in the period 2011 to 2014. The project was developed in collaboration with the KwaZulu-Natal Department of Health and UNICEF by Virtual Purple Health Systems (VP) and the Praekelt Foundation.

The project MomConnect aimed to use mobile technology to improve the uptake of prevention of mother-to-child transmission (PMTCT) services and improve the health outcomes of mothers and infants on the project.

MomConnect project design The key aims of the project were:

To pilot a text alert messaging system in the KwaZulu-Natal (KZN) province to strengthen the continuum of PMTCT care.

To integrate the text alert messaging system with an electronic patient record-keeping system.

To improve communication links between clients and community care givers through the mobile technology platform.

To create a mechanism to enable women from the community to provide feedback and communicate more actively with the health system. (Not implemented by VP and therefore not evaluated by MatCH.)

A target of 6000 women were to participate in the project. Women who enrolled in the programme were to receive SMSs in the language of their choice (English, isiZulu or seSotho) reminding them of their clinic visits and providing information on PMTCT, HIV prevention, infant feeding and pregnancy.

Project timeline The project was launched in June 2011. Message protocols were developed by May 2012 and personnel were trained from January to June 2012. Enrolment of clients commenced in July 2012. In February 2013 it was found that over 90% of enrolled mothers were not linked to clinic visits and messaging was suspended to allow retrospective linking of eligible clients. Data from clients who had not received messages was disregarded. A change in National Guidelines in April 2013 impacted on the study design and messaging was suspended, but resumed in June 2013. 5044 women were enrolled by the close of the project when evaluation took place in October 2014.

Evaluation methodology MatCH was contracted by UNICEF to conduct a rapid evaluation of the MomConnect project, including a desk review, process evaluation and quantitative and qualitative analysis of the project.

The quantitative analysis explored the project achievements and the messages delivered, based on available data from the project.

Qualitative data collection from clients aged 18 years and older was conducted by MatCH in eThekwini and Umgungundlovu districts at ten facilities where the MomConnect project had been fully implemented.

The study population for the qualitative data collection was 574 women enrolled on MomConnect. A second study population of healthcare workers at both active enrolment sites and inactive sites was also interviewed.

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The evaluation used a mixed method study design. A total of 60 semi-structured interviews were conducted with women who received SMSs during the course of the project. In addition, 37 healthcare workers from 37 facilities participating in the project were interviewed in the two districts.

Quantitative findings As per the MomConnect December 2014 summary report, 5044 clients were enrolled by December 2014 (1796 in Umgungundlovu and 3248 in eThekwini). This suggests that at least 6000 had been enrolled in the project by 2015 as stipulated in the original project proposal. Overall, one third of clients were enrolled at less than 15 weeks’ gestation, a further third enrolled between 15 and 20 weeks’ gestation, and the final third enrolled after 20 weeks’ gestation. This is in keeping with the District Health Information System (DHIS) estimates of the proportion of clients that enrol for antenatal services before 20 weeks’ gestation. Approximately 40% of clients were HIV-positive at the time of enrolment, in keeping with the Antenatal Sentinel HIV Sero-prevalence data for KZN.

From 14 June 2013 till 25 August 2015, 42 680 text messages were sent to enrolled clients by MomConnect text messaging system, of which 41 815 were scheduled messages and 865 were triggered messages.

No conclusions can be drawn from DHIS data based on the limited available data from the Virtual Electronic Medical Record system (VEMR) for review.

Qualitative findings There was an extremely positive response to the SMSs by the clients – they liked them and found them to be helpful. Most clients understood the SMSs and would have liked them to continue for longer. A number of clients said that SMSs were not always delivered to them and they were concerned about that. Most clients had disclosed to someone else that they were receiving the SMSs. The majority of clients said they would recommend the service to someone else.

Healthcare workers generally felt the project was not effective and that training and support had been limited. They mentioned various technological, organisational and behavioural challenges that contributed to the lack of effectiveness of the project. Some of the workers used data in the management of patients but information was not always recorded timeously. Real-time data entry was required for the correct timing of SMSs, but this did not take place at many facilities. The healthcare workers recommended more training to aid the success of the project.

Discussion The MomConnect KZN project achieved enrolment of approximately 6000 clients in two districts in KZN by 2015, thus reaching the proposed target. The number of scheduled text messages for all categories of clients increased over time confirming successful scale-up of the project at all sites. The data reviewed in this evaluation confirms that the text messaging service was successfully implemented for scheduled visit reminders and health information.

No data was available for this evaluation to ascertain if integration of text messaging and patient medical record system was successful overall, and whether this integration had any effect on the cascade of care.

There is no data relating to the establishment of a communication channel with community care givers. The aim of creating a communication feedback mechanism between clients and the health system was technically achieved as a register of these feedback messages is available. However, it is not clear whether this system is responsive and improves adherence to follow-up visits.

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Clients overwhelmingly liked the SMSs and it is apparent that a system that provides timeous and reliable appointment reminders would be well-received. Healthcare workers need to be capacitated in terms of training and reliable technology. A data quality plan is essential to improve data validity, reliability and completeness.

Recommendations In order to support real-time data entry and a two-way feedback system – essential components for the success of the project – it will require investment in infrastructure and significant modification of the data collection system. Connectivity at health facilities needs to be improved and maintained.

Ongoing training and support from management is essential for healthcare workers.

Access to a call centre for clients to provide detailed explanations or referrals would be beneficial, as would a facility for keeping contact details up-to-date. Publicity would aid community buy-in and improve enrolment.

Thorough piloting of new systems is needed to fine-tune systems prior to wider rollout.

Conclusion The MomConnect project demonstrates that a scheduled text messaging system can be implemented in the public health system environment in KwaZulu-Natal.

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1 Introduction 1.1 Background

This report summarises key findings from a rapid evaluation of the KwaZulu-Natal Department of Health’s pilot mHealth project, MomConnect, implemented in eThekwini and Umgungundlovu districts in the period 2011 to 2014.

The project MomConnect aimed to use mobile technology to improve the uptake of PMTCT services and improve the health outcomes of mothers and infants on the project. Mobile technology offers opportunities to overcome a wide range of barriers in developing countries related to healthcare access and resources, increasing reach to services and information while reducing costs, increasing efficiency and improving the ability to diagnose, treat and track diseases.1

Mobile phones are ubiquitous in South Africa but their capabilities vary depending on the type of handset a user possesses, which dictates the type of communication platform used. However, 100% of phones are capable of receiving SMSs which is why this method dominates all other methods of mHealth communication. The increasing functionality of handsets means that other platforms are opening up for wider delivery of mHealth services.

The lack of a unified patient record system in South Africa coupled with a high disease burden, and the pervasive nature of mobile phones in this resource-poor country together with a weak healthcare infrastructure, has made health communication directly with patients rather than clinics a viable and useful option in South Africa2,3 and this can be achieved through mobile phones.

The South African eHealth strategy 2012-2016 was published on 9 July 2012 and provides the basic foundations for future integration and coordination of all eHealth initiatives in the country (both public sector and private sector)4 and encourages a collaborative approach by leveraging partnerships between, for instance, the private sector, NGOs, other government departments, other country governments, and research organisations.

There are a range of challenges facing eHealth, including, amongst others:

Widely differing levels of eHealth maturity across and within provinces.

A large number of disparate systems between which there is little or no inter-operability and communication.

Broadband connectivity is expensive and still out of reach for many.

Tomlinson had noted that while sub-Saharan Africa displays a keen interest in effective mHealth interventions, not much is known about their success. Two systematic reviews5,6 on text messages have illustrated an evidence base of improvement in attending appointments, but these reviews did not include studies from resource-limited settings. The MomConnect project was designed to address this gap.

Several mHealth projects have been or are being run in South Africa. Important uses with regard to mHealth as it relates to HIV include:

providing information relating to prevention and general health

promoting services such as voluntary counselling and testing, by connecting individuals to existing clinics

encouraging patient adherence to antiretrovirals (ARVs) once they are on treatment

supporting patients on disclosure and stigma issues

providing information to pregnant women and new mothers on infant care and testing

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supporting healthcare workers in their work by decreasing time and increasing operational efficiency

improving data-gathering and analysis for service management

adapting phones for use as a portable diagnostic tool.7,8

1.2 South African mHealth interventions for PMTCT

1.2.1 Project Kopano

Project Kopano was a 3-month pilot project in 2010 that aimed to support women in the PMTCT programme in Pretoria. Women in the group communicated by SMS about issues affecting their lives during their pregnancies, such as HIV status, disclosing an HIV-positive status to others, medical treatment, breastfeeding and unemployment. Feedback showed the project assisted in overcoming support barriers, with its simplicity and anonymity allowing it to reach the most isolated of women.9

1.2.2 Babyinfo

Babyinfo (which is part of MXit Reach) provides women with freely accessible maternal health information as well as stage-based daily information on their pregnancy. User feedback has indicated that information of this type would assist mothers in remaining healthy during their pregnancy.10

1.2.3 Hi4LIFE

Hi4LIFE is a mobile phone service developed by HIVSA which provides women and their partners with information on HIV/TB, pregnancy and infant health. Over 100 000 people have opted in for the MXit service, mostly young and/or pregnant women. Over 40 000 people have used the Unstructured Supplementary Service Data (USSD) function and more than 300 000 targeted SMSs on pregnancy health tips have been sent out.11

1.2.4 iMobiMaMa

iMobiMaMa provides pregnant women with information and services to assist in the safe delivery of healthy babies, by encouraging early health services bookings and the monitoring of pregnancy progress for potential problems. The service records maternal health information, responding with individual specific information, which is achieved by linking mobile phones with medical devices that measure and test pregnancy milestones. Pregnant women register their pregnancies and monitor their milestones at local iMobiMaMA vending stations.12

1.2.5 SMSs to support PMTCT

A randomised trial in 2011, using SMS messaging, tested whether support messages could improve outcomes of PMTCT. This was run at a maternity hospital in Johannesburg where 386 women who were HIV-positive received SMSs on HIV-prevention medication, support on exclusive feeding, appointment reminders, motherhood tips, and positive living messages for the newly diagnosed for 10 weeks after birth. Results showed an increase in mothers who had their babies tested for HIV at 6 weeks and user feedback indicated that women viewed the messages as supportive and informative, with some women revealing that the messages helped them to accept their HIV-positive status.13

1.2.6 MAMA Alliance

MAMA South Africa was launched in May 2013 and aimed to provide age- and stage-based health information on maternal and child health and PMTCT of HIV, via mobile phones to new and expectant mothers. The MAMA SA programme communicated this information through five mobile

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“channels” – SMS, USSD, Mobisite, MXit and voice messaging. Data (collected through automated and manual methods), focus group discussions, and user feedback and testing indicated that users found the MAMA SA service valuable and highly acceptable.14,15

1.3 MomConnect project design

The MomConnect project was launched in June 2011. The project was developed in collaboration with the KwaZulu-Natal Department of Health and UNICEF by VP and the Praekelt Foundation. The project aimed to test the efficacy of detailed, personalised sets of SMSs for expectant and new mothers in the eThekwini and Umgungundlovu districts of KwaZulu-Natal.

A target of 6000 women from two hospitals (Prince Mshiyeni Memorial Hospital in eThekwini and Edendale Hospital in Umgungundlovu) and their 43 feeder clinics/community health centres were to participate in the project. Women who enrolled in the programme received SMSs in the language of their choice (English, isiZulu or seSotho) reminding them of their clinic visits and providing information on PMTCT, HIV prevention, infant feeding and pregnancy.

Messages would be received from the time of enrolment during antenatal care (up to 28 weeks gestation) until babies were 18 months old. At ‘opt-in’, the women’s HIV status would determine the set of SMS protocols they received, since positive and negative women were to receive different messages during antenatal and postnatal care. During the postnatal period, messages would be sent according to the infant feeding option chosen by the mother (exclusive breastfeeding or exclusive formula feeding).

The SMSs were linked to an electronic patient record enabling the tracking of the progress of the mother and baby. Messages included:

Informational messages about health safety in pregnancy and infancy based on the mother's gestational age and the infant’s age

Triggered clinical messages based on the interventions the mother and/or baby were scheduled to receive at different stages of pregnancy or post-delivery

Follow-up SMS reminders of imminent or missed appointments.

At the commencement of the project mothers were allocated to one of three groups: 1) Mothers who were HIV-positive and on antiretroviral therapy (ART)

2) Mothers who were HIV-positive and on AZT

3) Mothers who were HIV-negative or who did not know their HIV status.

After the change in guidelines, groups 1 and 2 were merged.

The key aims of the project were:

To pilot a text alert messaging system in the KwaZulu-Natal (KZN) province to strengthen the continuum of PMTCT care.




The project involved the implementation of two complementary technical systems – an Integrated Electronic Medical Record System (IePRS) and TxtAlert – which would allow early recognition of HIV-positive women eligible for ART, regular supportive messages and reminders for women on how to take ARVs, reminders of regular mother and infant postnatal visits, supportive messages and

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reminders for postnatal mothers on safer infant and young child feeding, and improved communication between patients and healthcare workers.

The initial expected results and impact of the project were to:

increase the number of HIV-positive antenatal care (ANC) clients having a CD4 test result

increase the uptake of retesting at 32 weeks

increase initiation on ART

increase infant uptake of Nevirapine

increase PCR testing for infants at 6 weeks

decrease PCR-positive rates at 6 weeks

increase infant testing at 18 months

decrease infant HIV-positive rates at 18 months.

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2 Project Timeline

Activity Date Challenges / Comments

Project Launch June 2011

Clinic Audit June 2011 Start-up duration took substantially longer than anticipated.

Technical Requirement Review and Set up

August-December 2011 Delays in setting up infrastructural requirements and procurement processes.

Development of Message Protocols

August 2011-May 2012 Development of message protocols required far longer than originally anticipated.

Personnel training January-June 2012 Ongoing training required as a result of staff turnover and a requirement for on-site mentoring.

Development of enrolment tools

June 2012

Enrolment of clients commenced

July 2012 Project implementation time frame required adjustment to accommodate late start-up.

Message suspension February 2013 Less than 10% of mothers enrolled found to be linked to clinic visits. Messaging was suspended to allow retrospective linking of eligible clients. Data from women who had not received messages was disregarded.

Change in National Guidelines April 2013 Impacted on study design, requiring amendments. Again, the project time frame required adjustment to accommodate the amendments.

Message suspension for change in guidelines

May 2013 Protocol amended based on the new guidelines (3 groups merged into 2 groups).

Messages resumed June 2013 Messages resumed for eligible women. Eligibility was based on amended protocols.

National Pregnancy Registry and Birth Defects Survey

November 2013 This additional national project was rolled at Prince Mshiyeni Memorial Hospital and feeder clinics.

Roll out of National MomConnect Project

August 2014 The National rollout overlapped with provincial MomConnect project.

5044 women enrolled by the close of the project

October 2014 Evaluation performed.

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3 Evaluation methodology

MatCH was contracted by UNICEF to conduct a rapid evaluation of the MomConnect project, including a desk review, process evaluation and quantitative and qualitative analysis of the project.

The quantitative analysis explored the project achievements and the messages delivered. The analysis is based on available data from the project. The rationale for the project was that the text alert messaging system would consist of scheduled stage-based health messages and personalised triggered reminders to decrease loss to follow-up and missed opportunities during the PMTCT and Maternal, Child and Women’s Health cascade of care.

The key aims of the project were:

To pilot a text alert messaging system in the KZN province to strengthen the continuum of PMTCT care.




Qualitative data collection from clients aged 18 years and older was conducted by MatCH in eThekwini and Umgungundlovu districts at ten facilities where the MomConnect project had been fully implemented.

The study population for the qualitative data collection was 574 women enrolled on MomConnect. A second study population of healthcare workers at both active enrolment sites and inactive sites was also interviewed.

The evaluation used a mixed method study design. A total of 60 semi-structured interviews were conducted with women who received SMSs during the course of the intervention. In addition, 37 healthcare workers from 37 facilities participating in the project were interviewed in the two districts.

Clients participating in the project were interviewed on services received, satisfaction with services, information received via the programme, and perceptions of the content and frequency of text messages, and suggestions for improvement.

Healthcare workers were interviewed on services provided, training and support given, knowledge of the programme, challenges and successes, and suggestions for improvement.

3.1 Overview of study design

Study participants were identified from facilities actively participating in the MomConnect project. The active enrolment sites are listed below in Table 1.

Table 1: Active sites in eThekwini and Umgungundlovu, KwaZulu-Natal Facility names: eThekwini Type Facility names: Umgungundlovu Type

Adams Mission Clinic Baniyena Clinic

Amanzimtoti Clinic Caluza Clinic

Danganya Clinic East Boom Clinic

Folweni Clinic Elandskop Clinic

KwaMakutha Clinic Mpumuza Clinic

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Facility names: eThekwini Type Facility names: Umgungundlovu Type

Magabheni Clinic Ndaleni Clinic

Nsimbini Clinic Pata Clinic

Odidini Clinic Richmond Clinic

Umbumbulu Clinic Sondelani/Ngubeni Clinic

Umlazi D Clinic Songonzima Clinic

Umlazi G Clinic Taylors Clinic

Umlazi H Clinic Mbalenhle CHC

Umlazi K Clinic

Umlazi U21 Clinic

Umlazi V Clinic

Umnini Clinic

Prince Mshiyeni Memorial Hospital Hospital

Table 2 lists the inactive/non-implementing sites. Healthcare workers were interviewed from both active (Table 1) and inactive sites (Table 2).

Table 2: Inactive/Non-implementing sites in eThekwini and Umgungundlovu Facility names: eThekwini Type Facility names: Umgungundlovu Type

Luganda Clinic Gomane Clinic

Umlazi AA Clinic Azalea Clinic

Mzamo Clinic Grange Clinic

Umlazi N Clinic Embo Clinic

Esigodini Clinic

Impilwenhle Clinic

Mbuthisweni Clinic

Ntembeni Clinic

Nxamalala Clinic

Sinathing Clinic

Willowfountain Clinic

Table 3 shows the women enrolled in the study by district.

Table 3: Women enrolled in eThekwini, Umgungundlovu and overall Indicator eThekwini Umgungundlovu Total

Total number of women enrolled 3248 1796 5044

Active facilities with enrolments 17 13 30

Enrolment < 15 weeks (# and %) 925 (28%) 666 (37%) 1591 (32%)

Enrolment 15 -20 weeks (# and %) 998 (31%) 487 (27%) 1485 (29%)

Enrolment 21 -28 weeks (# and %) 1122 (35%) 444 (25%) 1566 (31%)

Enrolment at delivery (# and %) 9 (0%) 135 (8%) 144 (3%)

Enrolment other (# and %) 194 (6%) 64 (4%) 258 (5%)

HIV + Status at time of enrolment (active) 1273 (39%) 704 (39%) 1977 (39%)

HIV – Status at time of enrolment (active) 1975 (61%) 1092 (61%) 3067 (61%)

Number of women (HIV- at first ANC visit) who test positive at later visit

30 (1%) 12 (1%) 42 (1.37%)

Number of DNA-PCR tests conducted 482 212 694

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Indicator eThekwini Umgungundlovu Total

Number of positive DNA-PCR test results 14 4 18

Number of HIV-positive women who have started treatment

10 3 13

3.2 Eligibility criteria Participants chosen for the client interviews had to meet the following eligibility criteria:

i. Women who were 18 years of age or older ii. Women who had received SMSs as part of the MomConnect project

Healthcare workers had to have been involved in the MomConnect project in order to fulfil the eligibility criteria for the interviews.

3.3 Recruitment of clients and healthcare workers The process of recruitment involved VP extracting from their database a list of clients scheduled to return for follow-up visits at scheduled periods. MatCH used this list to randomly select women to participate in the client interviews. This list did not include any health information on the clients from their medical records and only included facility name and contact details. Initially it was planned that more clients from eThekwini would be interviewed and that an equal number of clients would be identified at each visit, but as a result of delays in starting fieldwork, the majority of clients enrolled were returning for visits after 12 months. It was difficult to contact the women in the study to enrol the 60 women.

The recruitment of healthcare workers also took longer than anticipated. It was intended that the healthcare workers would be identified from the records of staff trained by VP. However, very few healthcare workers were identified through this mechanism. The researchers contacted each facility and requested to speak to an Operations Manager or Nursing Manager and relied on management to identify healthcare workers who had participated in the programme. We were able to enrol 37 healthcare workers.

The study population comprised pregnant women enrolled in the MomConnect project. Clients returning for appointments were stratified into two groups, those returning for a follow-up visit of less than 12 months and those returning for a 12-month or later follow-up visit. Mothers who were eligible in terms of age were selected for the study and invited to participate.

Table 4 provides an overview of the recruitment process for clients. The interviewers called 574 individuals on the recruitment lists provided. 70% of the numbers were not contactable despite repeated attempts and sending of SMSs. 9% of the numbers called were wrong numbers. 5% were not interviewed because the women were not available or had relocated and 1% were not interviewed as they had had a miscarriage or their baby had died. Two women were not interviewed because they reported that they had never received SMSs from the project despite being on the database. 19 women did not come for the interview.

The interview was scheduled to coincide with the visit to the healthcare facility. The interviews took approximately 45 minutes to administer and took place at the health facility. Clients did not incur additional costs besides the additional time for the interview and were provided with monetary reimbursement for their time and travel costs in accordance with the rate established by ethics committees.

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Table 4: Summary of recruitment process for clients Category No. %

Invalid cell phone number 18 3%

On voicemail/engaged 387 67%

Wrong number 53 9%

Not available for interview 19 3%

Relocated 9 2%

Excluded from interviews because of miscarriage or death of baby 7 1%

Not interviewed because never received SMSs 2 0%

Did not come for interview 19 3%

Interviewed 60 11%

Total 574

Healthcare workers at facilities that participated in the MomConnect project were invited to take part in the assessment. Table 5 provides an overview by site of the number of clients and healthcare worker interviews conducted. Healthcare workers were interviewed at their facilities. The timing of the interviews was scheduled to minimise service disruption where possible. The interviews took, on average, 30-40 minutes to conduct and were conducted in English.

Table 5: Summary of clients and healthcare workers interviewed

Site name Client interviews Healthcare worker interviews

Adams Mission 0 1

Amanzimtoti 0 1

Azalea 0 1

Caluza 0 1

Danganya Clinic 8 1

Embo 0 1

Edendale Hospital 0 1

Esigodini 0 1

Folweni Clinic 0 1

Gomane 0 1

Magabheni Clinic 0 1

KwaMakhutha 5 1

Mbalenhle CHC 7 1

Umnini Clinic 0 1

Mpilwenhle 0 1

Ndaleni 5 1

Sondelani Clinic/Ngubeni 0 1

Nsimbini Clinic 3 1

Nxamalala 0 1

Odidini Clinic 0 1

Pata 0 1

Prince Mshiyeni 0 1

Richmond Clinic 15 1

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Site name Client interviews Healthcare worker interviews

Sinathing 0 1

Songonzima 0 1

Taylors 0 1

Umbumbulu Clinic 6 1

Umlazi AA 0 1

Umlazi D 7 1

Umlazi G 0 1

Umlazi H 1 1

Umlazi K 3 1

Umlazi N 0 1

Umlazi U21 0 1

Umlazi V 0 1

Mzamo Clinic 0 1

Luganda Clinic 0 1

Total 60 37

3.4 Data collection and analysis

Data were collected by four experienced fieldworkers employed by MatCH. The interviewers all had Good Clinical Practice certification and were trained on the study protocol, ethics and data collection tools prior to embarking on the fieldwork. The English interview tool was translated into isiZulu and back-translated to ensure accuracy and validity. Data were collected during the period 4 June 2015 to 29 July 2015. All interviews were conducted in English or isiZulu depending on the preference of the client. The fieldworkers wrote notes on each interview. All healthcare workers were interviewed in English. All interviews were audio-recorded and translated and transcribed into English by the interviewers. All transcriptions were reviewed for accuracy by the team leader. Transcripts were then analysed using a grounded theory approach with inductive and deductive codes to classify themes.

3.5 Research ethics

The study received ethical clearance from the University of the Witwatersrand Human Research Ethics Committee (Medical), Certificate M150372, on 20 April 2015. The study was also reviewed by the National Department of Health Research Committee and approved on 12 May 2015.

All participants agreed to participate in the study voluntarily. No participants under the age of 18 were interviewed and all participants autonomously consented to be interviewed. The participants received an information sheet in the language of their choice (English or isiZulu) and provided written consent. Each participant received a copy of the informed consent for their reference.

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4 Results

4.1 Quantitative findings

The project evaluation reviewed progress against the stated aims of the project, which were:

To pilot a text alert messaging system in the KZN province to strengthen the continuum of PMTCT care.




It was intended that the project would have the following expected effects:

To enrol at least 6000 clients in two districts in KZN in the MomConnect project

To increase early ANC booking and early HIV testing in pregnancy

To increase HIV retesting rates in women who test HIV-negative at the ANC booking visit

To increase antenatal ART initiation

To decrease virological failure on ART during antenatal and postnatal periods

To increase exclusive breastfeeding rates

To increase 10-week and 14-week immunisation uptake rates

To increase proportion of women who attended the 6-day postnatal follow-up visit

To decrease HIV-positive proportion at 6- and 10-week DNA-PCR test and 18-month HIV rapid test during infant follow-up.

4.1.1 Enrolment

As per the MomConnect December 2014 summary report, 5044 clients were enrolled by December 2014 (1796 in Umgungundlovu and 3248 in eThekwini). This suggests that at least 6000 had been enrolled in the project by 2015 as stipulated by the original project proposal. Overall, one third of clients were enrolled at less than 15 weeks’ gestation, a further third enrolled between 15 and 20 weeks’ gestation, and the final third enrolled after 20 weeks’ gestation. This is in keeping with the DHIS estimates of the proportion of clients that enrol for antenatal services before 20 weeks’ gestation. Approximately 40% of clients were HIV-positive at the time of enrolment, in keeping with the Antenatal Sentinel HIV Sero-prevalence data for KZN. Table 6 below shows data collected for each cohort.

Table 6: Data collected for each Cohort (from VP) Category Umgungundlovu eThekwini Total

Total number of Women Enrolled 1796 (36%) 3248 (64%) 5044

Facilities with Cohort Data 13 17 30

Enrolment < 15 weeks 666 (37%) 925 (28%) 1591 (32%)

Enrolment 15 -20 weeks 487 (27%) 998 (31%) 1485 (29%)

Enrolment 21 -28 weeks 444 (25%) 1122 (35%) 1566 (31%)

Enrolment at delivery 135 (8%) 9 (0%) 144 (3%)

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Category Umgungundlovu eThekwini Total

Enrolment other 64 (4%) 194 (6%) 258 (5%)

HIV+ Status at time of enrolment 704 (39%) 1273 (39%) 1977 (39%)

HIV- Status at time of enrolment 1092 (61%) 1975 (61%) 3067 (61%)

Number of women who test HIV+ at subsequent visit

12 (1%) 30 (1%) 42 (1.37%)

Number of DNA-PCR tests conducted 212 482 694

Number of positive DNA-PCR test results 4 14 18

Number of HIV+ infants who have started treatment

3 10 13

4.1.2 SMSs sent

From 14 June 2013 till 25 August 2015, 42 680 text messages were sent to enrolled clients by MomConnect text messaging system, of which 41 815 were scheduled messages (Graph 1) and 865 were triggered messages (Graph 2).

Graph 1: Scheduled text messages

4948

15725

21142

696 130 390

5000

10000

15000

20000

25000

2013 2014 2015

Scheduled text messages by year (N = 41815)

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Graph 2: Triggered text messages

The distribution of text messages over time in HIV-positive clients (Graph 3) and HIV-negative clients (Graph 4) is consistent, displaying a pattern of increased messaging over time due to the increasing number of enrolled clients and increasing number of follow-up visits conducted over time.

Graph 3: Text messages sent to HIV-positive women by year

4948

696 130 39

0

5000

10000

15000

20000

25000

2013 2014 2015

Triggered Text messages by year (N = 865)

Triggered:

0

100

200

300

400

500

600

700

800

900

2015

2014

2013

21

Graph 4: Text messages sent to HIV-negative women by year

4.1.3 DHIS data review

No conclusions can be drawn from DHIS data based on the limited available data from the VEMR for review.

4.1.4 Cohort reports

VP provided the cohort reports for 2013 and 2014 clients enrolled on the project (below). As a result of the limited data entered into the electronic patient record, the evaluation was not able to ascertain any client outcomes or to measure the magnitude of the effect of implementation of integrated system on the PMTCT cascade of care. VP reported several challenges with data collection for the project. This included being unable to confirm if DNA-PCR tests were conducted for exposed infants, if rapid tests were conducted for infants at 18 months, lack of capturing of postnatal visit data (as evidenced by the large number of women with no data on follow-up visits) and not being able to track loss to follow-up. The tables below describe the data available. No further analysis of the data was possible.

Table 7: 2013 Cohort 2013 Cohort HIV-negative HIV-positive

<=14 weeks

15-20 weeks

21-28 weeks

Other Total <=14 weeks

15-20 weeks

21-28 weeks

Other Total

Number enrolled 527 522 586 130 1765 401 317 287 127 1132

Number of ANC visits 1469 1280 1245 65 4059 1020 885 693 66 2664

Average number of antenatal visits

2.8 2.5 2.1 0.5 2.3 2.5 2.8 2.4 0.5 2.4

Number of women delivered

523 519 577 130 1749 387 302 281 121 1091

Number of postnatal visits 1544 1888 2078 340 5850 1123 1301 1423 323 4170

0

200

400

600

800

1000

1200

2015

2014

2013

22

2013 Cohort HIV-negative HIV-positive

Average number of postnatal visits

3.0 3.6 3.6 2.6 3.3 2.9 4.3 5.1 2.7 3.8

Number of women with no 6-week visit documented

209 193 274 76 752 194 171 199 64 628

% of women with no 6-week visit documented

40% 37% 48% 58% 43% 50% 57% 71% 53% 58%

Number of HIV exposed infants at 6 weeks who are HIV+

0 6 0 5 0 11


200 214 292 80 786 182 177 191 62 612


38% 41% 51% 62% 45% 47% 59% 68% 51% 56%


223 195 273 82 773 201 172 188 74 635


43% 38% 48% 63% 44% 52% 57% 67% 61% 58%

Number of women with no 6-month visit documented

240 222 302 96 860 218 191 201 80 690

% of women with no 6-month visit documented

46% 43% 53% 74% 50% 57% 63% 72% 48% 63%


101 168 264 134 667 62 70 83 90 305


72% 62% 68% 69% 67% 47% 45% 50% 74% 53%

Number of exposed infants with positive HIV test at 18 months

0 0 0 0 0 0

Number of women lost to follow-up (no visit in last 3 months)

212 188 262 63 725 228 238 183 53 702

Table 8: 2014 Cohort 2014 Cohort HIV-negative HIV-positive

<=14 weeks

15-20 weeks

21-28 weeks

Other Total <=14 weeks

15-20 weeks

21-28 weeks

Other Total

Number enrolled 353 399 428 120 1300 291 247 264 74 876

Number of ANC visits 1021 1058 1050 201 3330 913 765 702 146 2526

Average number of antenatal visits

2.9 2.7 2.5 1.7 2.6 3.1 3.1 2.7 2.0 2.9

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2014 Cohort HIV-negative HIV-positive

Number of women delivered

348 392 418 116 1274 288 242 260 68 858

Number of postnatal visits 612 598 713 300 2223 464 514 556 177 1711

Average number of postnatal visits

1.8 1.5 1.7 2.6 1.7 1.6 2.1 2.1 2.6 2.0


183 212 244 68 707 153 118 144 30 445


53% 54% 58% 59% 55% 53% 49% 55% 44% 52%

Number of HIV exposed infants at 6 weeks who are HIV+

0 2 4 1 1 8


192 223 264 79 758 156 129 162 39 486


55% 57% 63% 68% 59% 54% 54% 62% 57% 57%


218 262 303 92 875 170 155 189 48 562


63% 67% 72% 79% 69% 59% 64% 73% 71% 66%


196 282 297 93 868 161 162 182 43 548


65% 74% 71% 80% 71% 62% 69% 70% 63% 67%


6 12 18 3 39 6 5 7 3 21


55% 63% 75% 75% 67% 55% 42% 70% 38% 51%

Number of exposed infants with positive HIV test at 18 months

0 0 0 0 0 0

Number of women lost to follow-up (no visit in last 3 months)

124 148 162 44 478 106 118 134 48 406

4.2 Qualitative findings – clients

Qualitative Findings from interviews with 60 clients are summarised for this report. The demographic profile of the clients is reflected in Table 9.

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Table 9: Demographic profile of the clients interviewed for the evaluation

Clients were asked the following questions:

Whether they liked the SMSs

How frequently they wanted to receive messages and for what duration

Whether the SMSs were helpful

Whether they understood the SMSs

Whether they had received all the SMSs

Whether they had changed their cell phone number

Whether they were worried about someone seeing their SMSs

Whether they felt the messages were fine and if they had recommendations for

improvements.

Their responses are summarised below.

4.2.1 Whether clients liked the SMSs

59 women out of the 60 interviewed liked the SMSs. When prompted to respond on why they liked the SMSs, 38 said they liked the reminders, 12 liked the information received and 8 found the messages motivating.

Clients were asked about their favourite messages. 33 clients mentioned the appointment reminders, 4 mentioned the immunisation reminders and 4 the messages about taking their baby to the clinic or baby health messages.

Messages recalled by the women included appointment reminders (55 women), taking baby to the clinic (46 women), immunisation (28 women), HIV prevention (16 women) and ART (14 women). Others recalled messages about fertility planning (7 women), breastfeeding (6 women), healthy eating (5 women) and hygiene (2 women).

14 clients reported feeling at a loss when the SMSs stopped at the end of the project.

4.2.2 Frequency and duration

Clients were asked how frequently they wanted to receive messages and for what duration. The answers received were very varied, ranging from ‘as often as possible’ to ‘monthly’. The duration requested ranged from 12 months to 18 years. The most requested duration was for 2 years.

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4.2.3 Benefit

58 of the 60 women interviewed felt the SMSs were helpful. Women mentioned that the SMSs provided information they needed and reminded them of appointments. HIV-positive women felt the messages provided them with hope.

4.2.4 Understanding

48 women out of the 60 said they understood the SMSs, while 5 women said they did not. Although clients had chosen the language in which to receive SMSs, in some cases the choice made was not understood. The isiZulu translation of some terms caused confusion.

The clients were asked if they had had any questions about the SMSs. 37 answered that they had no questions, while 7 did have questions. 5 of the 7 had gone to a healthcare worker with their questions. One woman, however, reported being too frightened of the nurses to ask them questions.

4.2.5 SMS delivery

22 women felt that the SMSs were not always delivered to them, while 8 women felt they received all their SMSs. 13 clients were upset about not receiving all the SMSs.

4.2.6 Cell phone numbers

The clients were asked whether they had changed their cell phone number. 26 women reported having had the same cell phone number since enrolment, while 3 women had changed their number during the project. Women reported various reasons for changing their numbers which included their phones being blocked, lost or stolen, network problems and defective cell phones. It was evident when the evaluators tried to contact women from the project data base that many women had changed their numbers since the start of the project with more than 500 women contacted to successfully recruit the 60 women for the evaluation.

4.2.7 Disclosure

Clients were asked if they were worried about someone seeing their SMSs. 33 women said they were not worried about it, while 3 women had concerns. All 3 of the women concerned were HIV-positive. However, all 3 had disclosed to a confidant that they were receiving SMSs and none had experienced anyone finding out about the SMSs accidentally. 34 of all the respondents had told someone about the SMSs. 18 had told a sexual partner or the baby’s father, 13 had told a family member, 3 had told friends and 2 had told other mothers of infants. 18 HIV-positive women had told someone about the messages and 10 of those had disclosed the messages to their partner. 20 of the women had shared the messages with someone else. 12 clients said they had shown someone the SMSs on their cell phones, but none reported any problems as a result.

4.2.8 Client feedback on the messages

11 clients felt the SMSs were fine as they were, while 12 clients made recommendations, including: providing information on additional topics not covered (8 women), extending the duration of the period over which the SMSs would be sent (2 women), receiving the SMSs in another language (1 woman) and making them simpler to understand (1 woman). 35 clients said they would recommend the SMSs to someone else. Only 1 client felt that the SMSs had not helped her and said she would not recommend them.

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4.3 Qualitative findings – healthcare workers

37 healthcare workers were interviewed. The breakdown by district and cadre is provided below (Table 10). This included 20 healthcare workers from sites that had managed to implement the project as well as 17 healthcare workers from sites where the project was not implemented. Table 11 provides a summary by implementation status.

Table 10: Summary by district and cadre of provider Operations

Manager Professional

Nurse Data

Capturer / Clerk

Counsellor/CCG

Total

eThekwini 3 8 7 2 20

Umgungundlovu 2 11 3 1 17

Total 5 19 10 3 37

Table 11: Summary by implementation status Operations

Manager Professional

Nurse Data

Capturer / Clerk

Counsellor/CCG

Total

Implementing 3 12 8 2 25

Non-Implementing 2 7 2 1 12

Total 5 19 10 3 37

Staff from 9 facilities that were unable to implement the project at all due to extreme difficulties were interviewed (7 from Umgungundlovu and 2 from eThekwini). 4 staff were interviewed from facilities that no longer had anyone implementing the project (2 each from eThekwini and Umgungundlovu) and 25 staff were interviewed from facilities that were able to implement the project (16 from eThekwini and 9 from Umgungundlovu).

Staff were interviewed on:

The effectiveness of the project

Their perception of training and support provided

Technological, organisational and behavioural challenges they encountered

Handling of data and data use

Recommendations for improvements that they may have.

4.3.1 Effectiveness of the project

16 healthcare workers felt the project was not effective, 4 felt the project was effective and 4 had mixed responses. Their reasons included: clients not receiving the SMSs (2 respondents), enrolments too low to see an impact (2 respondents), clients having questions about the SMSs (1 respondent), complaints about the isiZulu SMSs (1 respondent), and clients still not attending appointments (2 respondents). 6 healthcare workers felt the SMSs did remind clients to attend appointments.

4.3.2 Training and support

When healthcare workers were asked about the training provided by the project, 5 healthcare workers mentioned attending an off-site training session, 5 were trained on site, one mentioned being trained by someone from the health facility on site, and 4 mentioned that the training was

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only on data-capturing. In one case, the trained person had left the facility. One healthcare worker felt the training provided was sufficient, 3 felt that the training was insufficient, and one reported never having been trained. 6 staff mentioned on-site follow-up support from VP and one reported telephonic support. 2 healthcare workers felt there was no support either from VP or from the Department of Health and another one felt the support was insufficient. 8 healthcare workers said they had not implemented the programme and therefore could not comment on the support.

4.3.3 Technological, organisational and behavioural challenges

Technological challenges mentioned by healthcare workers included problems with network and connectivity (15 workers), computer problems – viruses, lost data (5 workers), limited computer literacy (3 workers), problems entering client data on the electronic record (2 workers), challenges with getting computers installed at municipal facilities (1 worker) and complaints from clients that they did not receive SMSs (1 worker).

Organisational challenges relayed by healthcare workers that impacted on the project included that not all staff at facilities were trained on the project (15 workers) and, more specifically, that nurses had not received training on the project (6 workers). 5 healthcare workers mentioned the limitation of only one staff member being able to register clients, 3 workers mentioned staff rotation and one mentioned staff resignations as being factors resulting in challenges. Other challenges relating to organisational factors included incomplete data in files (3 workers), clients receiving services at multiple entry points (2 workers), clients taking their charts home (1 worker), client data not being entered for registered clients (1 worker) and the long time it took to complete data entry (1 worker).

Behavioural challenges cited by healthcare workers included women without their own cell phone (11 workers), women who changed their cell phone numbers (5 workers), women who were scared of being called by project staff (3 workers), clients changing clinics (3 workers), clients giving false addresses (3 workers), clients who had not disclosed their HIV status (2 workers), clients’ limited literacy (2 workers) and clients giving wrong cell phone numbers (1 worker). One healthcare worker also mentioned that clients reported that their partners were suspicious of the SMSs.

4.3.4 Data utilisation

Healthcare workers were asked how they used the project data. Only 8 of them reported using the data. Data was used for the management of patients, reporting and patient follow-up. Healthcare workers were asked how they entered data into the system. 8 reported that they entered data directly from patient files, 5 entered both from files and directly into the system, three reported entering data after the fact and one entered data monthly. Real-time data entry was required for the correct timing of SMSs, but this did not take place at many facilities. Healthcare workers reported being too busy to enter patient data in real time.

4.3.5 Healthcare worker recommendations

Healthcare workers were asked to make recommendations for future projects of this nature. 12 healthcare workers mentioned more training was needed. This included more staff being trained at each facility on the project, training of both data capturers and nurses on the project, training on data entry, and computer literacy training. 3 healthcare workers wanted improved connectivity, 2 wanted more supervision and more staff to register clients. 2 healthcare workers suggested that better use could be made of the record system and one recommended the registration of all mothers while another suggested that there should be more space in the facility. One healthcare worker proposed giving incentives for clients to register.

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5 Discussion

The MomConnect KZN project achieved enrolment of approximately 6000 clients in two districts in KZN by 2015, thus reaching the proposed target. The number of scheduled text messages for all categories of clients increased over time confirming successful scale-up of the project at all sites. The data reviewed in this evaluation confirms that the text messaging service was successfully implemented for scheduled visit reminders and health information.

No data was available for this evaluation to ascertain if integration of text messaging and patient medical record system was successful overall, and whether this integration had any effect on the cascade of care.

The project did not end up implementing a communication channel with community care givers. The aim of creating a communication feedback mechanism between clients and the health system was technically achieved as a register of these feedback messages is available. However, it is not clear whether this system is responsive and improves adherence to follow-up visits.

Clients overwhelmingly liked the SMSs for a wide range of reasons including information and appointment reminders. From the findings it seems apparent that a system that provides timeous and reliable appointment reminders would be well-received. Clients did express negative feelings when the SMSs were not received and client expectations need to be managed. Language issues and communicating complex ideas in SMSs is a challenge.

Ways to deal with clients losing cell phones and changing their numbers will need to be built into programmes such as a mechanism to report that a cell phone number is no longer operational. Technology can play an important role in patient communication but needs to be part of a package of care as clients may still have unanswered questions or additional needs. Healthcare workers need to be capacitated to deal with client queries or concerns otherwise they may feel disempowered when these are raised by clients coming for services.

However, regardless of client opinion, if the project is not properly implemented or factors prevent its full implementation, the benefits will be limited. Healthcare workers will need support and mentoring to roll out new programmes. Dealing with healthcare workers’ fears and negative perceptions about electronic record-keeping systems should be part of the rollout of new systems. Building confidence and capacity among healthcare workers and having mechanisms to resolve IT and other challenges are clearly needed. Ensuring that facilities are adequately set up from the beginning of new programmes is necessary. Without the resources and infrastructure necessary for implementation, healthcare workers and clients may get frustrated. Technology needs to be seen as beneficial by both the healthcare workers and the clients. Improving this aspect of the project may have resulted in a greater uptake and utilisation of MomConnect. A good understanding of the processes of data collection is needed to design health information systems. This will help to ensure that the data required for the system is being collected timeously. A data quality plan is essential to improve data validity, reliability and completeness. Standardised record collecting tools for post natal care would have greatly assisted the collection of outcome data necessary to evaluate the project. Responses to the challenges and problems raised by both clients and healthcare workers is the next step in taking projects such as MomConnect to the next level.

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6 Limitations

VP provided limited project data for evaluation.

As a result of delays in ethics approval and obtaining data from VP, most of the clients had already had their babies. This meant that no clients were receiving ANC messaging at the time of the study. SMSs were most frequent during the ANC period and client recall may have been higher among clients during this period.

No data linking how many SMSs the interviewed clients received were available to compare with their responses. No clients under 18 years of age were interviewed – they may have had different opinions on the SMS.

It was difficult to recruit clients for the study as about 90% of registered clients on the provided lists were not contactable. Most clients needed to be called repeatedly. The clients we were able to reach may have received more SMSs and have had a more favourable view of the programme than those we were not able to contact. Clients also did not always attend appointments set up by the researchers and it was difficult to hold interviews in busy clinics. MatCH appreciates that facility staff made space available for us to interview clients in some congested clinics.

The fact that the evaluation only took place in 2015 meant that many healthcare workers who had been with the project at the start had left and could not be interviewed. VP records on healthcare workers who participated in the project were also incomplete.

Some confusion between the KZN MomConnect and the National MomConnect programme was observed. Where respondents were found to only have knowledge of the national programme this was noted in interviewer notes.

Scheduling interviews with healthcare workers was a challenge, and privacy and time constraints may have hampered the amount of information received from some respondents. Despite the busy schedules of Operations Managers, MatCH was well-received at clinics, and healthcare workers made time to provide their feedback on the project. Although there was an initial delay in getting permission to interview municipality staff, this was later successfully secured.

MatCH was not able to contact some of the facilities (mostly those that were not able to implement the project) and some facilities were not able to identify any respondents to interview. This may have biased the findings in favour of facilities that were better able to implement the project.

This evaluation was conducted as a retrospective review of the available data and narrative reports. No other data were available for analysis on project outcomes.

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7 Recommendations

Further analyses and evaluation of the MomConnect implementation is essential to understand the cost-benefit ratio of this mHealth project. Ongoing evaluation of cohort data is required to create a more comprehensive view of the project achievements.

Respondents liked the appointment reminders but for these to be effective, it requires real-time data entry on appointment dates and a two-way feedback system to identify and report back on clients who attend appointments. In order to adequately support this feature it will require significant modification of both the data collection system and investment in infrastructure. The opportunities for linking this kind of system to retention in care strategies such as defaulter tracing and home visits are potentially huge and could contribute substantially to reaching 90:90:90 targets.

Care needs to be taken that the system is working properly before rolling it out as clients quickly become dependent on systems and may have negative responses when technology does not work as planned.

Clients have a wide range of needs and levels of understanding. Options to customise information and to provide access to a call centre for more information and to provide more detailed explanations or referrals is likely to be beneficial.

A mechanism for clients to report lost cell phones or a change in contact number would improve the retention of clients in the programme. Routine follow-up on any change in contact details should be done at each visit to ensure patients can be traced. Obtaining a secondary contact number would be useful for following up on clients not returning to facilities.

Readiness indexes and implementation guides must be in place at the start of the project, as well as the necessary infrastructure and support, in order for the project to be successful. Connectivity at health facilities needs to be improved and maintained in order to ensure improved patient information and data utilisation for planning and performance management.

Linking patient information to other technology such as appointment reminders, electronic receipt of laboratory results, apps for caregivers doing home visits and job aids for healthcare workers could expand the utility of MomConnect and have the potential to have a greater impact on quality of care.

Ongoing training and support from management is needed for full implementation of any new intervention.

It is important to obtain community and healthcare worker buy-in for a new project, and publicity is likely to improve enrolment and uptake. Having a mechanism to provide feedback is also important for both clients and healthcare workers to feel like they are being heard.

Healthcare workers may get frustrated if a new programme is too challenging to implement at the outset. It is recommended that a small pilot be undertaken where the systems can be tested and improved on to ensure the project is implemented at an intensity that would give results. Thorough piloting of new systems and a quality improvement approach is needed to fine-tune systems prior to wider rollout.

Standard record keeping tools need to be in place to ensure the collection of post natal care data and determine the outcomes of the project. A data management plan is needed from the outset of a new project to ensure that there are systems to collect the data required for operations. Data quality plans should be a built-in part of the data management system to ensure data completeness,

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validity and reliability. Data is more likely to be used if user-friendly and helpful reports can be extracted. Systems need to be designed with the user in mind.

8 Conclusion The MomConnect project demonstrates that a scheduled text messaging system can be implemented in the public health system environment in KwaZulu-Natal; many technical and logistical problems have been resolved that will aid future scalability. It is not clear if integrated patient medical record systems will increase the magnitude of the effectiveness of this intervention or if it is feasible at a national level.

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Conducting a Rapid Assessment of MomConnect Project from ... · Natal Department of Health and UNICEF by Virtual Purple Health Systems (VP) and the Praekelt ... The South African