"Friendly reminder: hi! It is that time again âŸº": understanding PMTCT care text message design preferences amongst pre- and post-partum women and their male partners.

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RES E AR C H A R T I C L E Open Access

“Friendly reminder: hi! It is that time again

☺”: understanding PMTCT care text

message design preferences amongst pre-

and post-partum women and their male

partners

Natabhona M. Mabachi

, Melinda Brown

, Catherine Wexler

, Kathy Goggin

, May Maloba

, Dama Olungae

Brad Gautney

and Sarah Finocchario-Kessler

Abstract

Background: Prevention of mother-to-child HIV transmission (PMTCT) services in Kenya can be strengthened

through th e delivery of relevant and culturally appropriate SMS messages.

Methods: This study reports on the results of focus groups conducted with pre and postnatal women living with

HIV (5 groups, n = 40) and their male partners (3 groups, n = 33) to elicit feedback and develop messages to

support HIV+ women’s adherence to ART medication, ANC appointments and a facility-based birth. The principles

of message design informed message development.

Results: Respondents wanted ART adherence messages that were low in verbal immediacy (ambiguous), came

from an anonymous source, and were customized in timing and frequency. Unlike other studies, low message

immediacy was prioritized over customization of message content. For retention, participants preferred messages

with high verbal immediacy—direct appointment reminders and references to the baby—sent infrequently from a

clinical source.

Conclusion: Overall, participants favored content that was brief, cheerful, and emotionally appealing.

Keywords: PMTCT, Principles of message design, SMS, Kenya

Introduction

Globally, 90% of pediatric HIV infections result from

perinatal HIV transmission [1]. Without intervention,

transmission rates of HIV can be as high as 15–45%, but

with antiretroviral therapy (ART) rates can be reduced

to as low as 5% during pregnancy, delivery, and breast-

feeding periods [2]. Prevention of mother to child

transmission of HIV (PMTCT) programs are key to pro-

viding the range of services needed for women and in-

fants to reduce perinatal HIV infection. Such programs

support ART initiation and adherence, encourage ante-

natal care and safe childbirth practices, and provide HIV

virologic testing for infants exposed to HIV [3].

Consequently, PMTCT programs have prevented an

estimated 1.4 million pediatric HIV infections globally

between 2010 and 2018 [3]. In Eastern and Southern

Africa, perinatal HIV infection has declined from 18%

[15–25%] in 2010 to 9% [8–13%] in 2018. However,

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* Correspondence: [email protected]

Department of Family Medicine, University of Kansas Medical Center,

Mailstop 3064, 4125 Rainbow Blvd., Kansas City, KS 66160, USA

Full list of author information is available at the end of the article

Mabachi et al. BMC Public Health (2021) 21:1491

https://doi.org/10.1186/s12889-021-11444-x

challenges engaging and retaining women in the pre- and

post-natal cascade of care remain due to stigma and

discrimination, limited facility resources, poor male

partner support, gender inequality and economic

marginalization [3, 4].

The use of mobile health (M-health) technology has

proven to be an effective strategy in many settings to

support engagement and retention in PMTCT services

and increase early infant diagnosis (EID). Randomized

trials have shown that sending short text messages is ef-

fective in improving anti-retroviral treatment (ART) ad-

herence, viral suppression, and attendance of pre- and

post-natal clinics [5–8]. The ubiquity of mobile phones

in low resource settings led the United Nations to en-

courage the use of mobile phones as a commun ication

strategy to provide reminders to pregnant women living

with HIV and their male partners and support consistent

engagement in the PMTCT cascade of care [ 9].

Involving participants in creating message content can

be key to ensuring acceptability and appropriateness. In-

deed, previous qualitative research in Kenya found that

including participants in message creation alleviated

concerns regardin g privacy and unintentional disclosure

with SMS-based reminders that could lead to marital or

family discord [10]. Previous studies report that women

prefer text message content to be polite and encour-

aging, provide informational support and reminders to

take medication, attend antenatal and postnatal appoint-

ments and to engage partners [5, 7, 10].

In this study, we wanted to get a better understanding

of the features of text messages including content, tim-

ing and characteristics such as tone, that would be mo-

tivating to HIV+ mothe rs to engage in targeted

behaviors. We document the qualitative process of get-

ting feedback and input on SMS message content with

HIV+ pre/post-natal mothers and their male partners,

with the aim of creating appropriate mess ages to en-

courage consistent ART adherence, engagement in ante-

natal clinic (ANC) appointment attendance, and a

facility-based delivery.

Methods

This qualitative study was embedded within an interven-

tion development study in Kenya (R34MH107337) , de-

signed to develop and pilot a PMTCT component of the

HIV Infant Tracking System (HITSystem ) - a system-

level, web-based mHealth intervention designed to im-

prove postnatal EID outcomes. Using electronic alerts to

providers and SMS text messages to mothers, the new

PMTCT compon ent of the HITSystem (v 2.0) tracks

women with HIV throughout their pregnancy to support

ART adherence, antenatal appointment attendance, hos-

pital delive ry, and linkage to EID services [11]. We also

leveraged a supplement (R01HD076673–04 S1) piloting

HITSystem 2.0 at four intervention sites to conduct this

formative research. Sites were in geographically distinct

counties of Kenya: Nakuru County, Mombasa County,

Kakamega County, and Na ndi County. Adult HIV preva-

lence (and ART cover age) in 2014 were 5.9% (66%) in

Kakamega, 7.4% (98%) in Mombasa, 5.3% (62%) in Na-

kuru, and 3.7% (82%) in Nandi [12]. Study sites in Kaka-

mega and Mombasa Counties were urba n, while sites in

Nandi and Nakuru Counties were rural. Qualitative data

reported here were used to inform the development of

the text messaging component of the HITSystem 2.0.

Study participants

In August 2016, we conducted separate focus group dis-

cussions (FGD’s) with (1) HIV+ pregnant and/or postna-

tal women (5 focus groups, total of 40 participants) and

(2) a subset of male partners who regularly accompanied

their partners to their antenatal clinic (ANC) appoint-

ments (3 focus groups, total of 33 participants). The

Nandi site had two female FGD’s and no male, while all

other sites had 1 each of female and male FGD. Since

these participants were already engaged with the topic of

PMTCT, we felt they were best placed to provide insight

on SMS content preferences. FGD’s (see Additional file

1 for questions) were conducted as part of formative

work prior to any interaction with the HITSystem 2.0.

Rather than individual interviews, we chose to conduct

focus groups as research indicates that a group dynamic

can be particularly useful for vetting and generating

message content customized for the range of behaviors

targeted by this intervention [13, 14].

Message design

As this was the formative arm of the study, we devel-

oped messages prior to conducting the FGD by drawing

from literature on information processing theory [15]

and message design [16]. Information processing theory

[15–17] posits that people who actively process a mes-

sage are more likely to engage, comprehend, and posi-

tively evaluate that message; increasing the likelihood of

enacting the targeted positive behavior. Literature sug-

gests that aspects of message design [18] including: ver-

bal immediacy (degree of directness and explicitness),

message tone (cheery, serious, value free), message

source (community worker, health professional, ambigu-

ous), message length, message frequency, message tim-

ing, message visuals (emoji’s, symbols), and message

language (Kiswahili, English, vernacular, sheng) could

encourage active processing from HIV+ pregnant/post-

natal women and their partners. With this in mind, and

after consulting with our Kenyan partne rs (Mentor

Mothers (HIV positive peer educators), project site coor-

dinators and nurse Co-PI) who work directly with the

mothers and have an understanding of the types of

Mabachi et al. BMC Public Health (2021) 21:1491 Page 2 of 10

messages that could resonate with participants, we de-

veloped fourteen messages to pilot during the FGD’s

(see Additional file 1 FGD questions). Table 1 outlines

the messages that were piloted and the characteristics of

these messages that we felt would theoretically encour-

age active processing and make them more likely to suc-

ceed. Messages in bold indicate messages preferred by

women while those with an asterix by men. Messages

that have both indicate points of agreement between

mothers and male partners.

Procedures

We employed a purposive strategy recruiting pregnant

and postnatal women living with HIV who were enrolled

in PMTC T care at three of the planned HITSystem 2.0

intervention sites, and a subset of their male partners.

Mentor mothers (women living with HIV who have

completed PMTCT and employed at the hospital to pro-

vide support to PMTCT clients) who had an established

relationship with female participants identified and

reached out to eligible women to participate in the

study. Participating women identified their eligible male

partners for inclusion. Permission was sought from

women with a current partner who had engaged in her

PMTCT/EID care before soliciting their participation in

male FGD’s.

Each FGD was sch eduled o n designated PMTCT

clinic days and had an average of 8–12 attendees,

with some participants joining late or leaving early,

depend ing on t heir availabili ty. This flexibility was de-

liberate to accommoda te interested and eligible par-

ticipants with varying clinic appointment times and

work schedules who would have otherwise bee n un-

able to join. There was always a minimum of 7 par-

ticipantsinthefocusgroupdiscussions,with1–3

participants having to leave early or join late per focus

group. While participants ability to leave early/join late

may have affected the discussion, we believe the benefit of

engaging participants particularly male partners who are

hard to reach, the limitation created by allowing partici-

pants to be present for only part of the conversation.

Focus groups were held in a quiet and private space at the

study hospital and lasted about 90 min. All participants

provided written informed consent and received 400

Kenya shillings (approximately 4 US dollars) in appreci-

ation of their time.

Focus groups were conducted in Kiswahili by re-

searchers trained in qua litative research methods. All

study procedures were approved by the Institutional Re-

view Boards at the Kenya Medical Research Institute

(KEMRI) and the University of Kansas Medical Center

(KUMC).

Table 1 Pilot SMS texts presented to participants

Message Type (FGD type)

English

Message Characteristics

ART Adherence (Women &

Male)

*“Friendly Reminder: Hi! It is that time again

”

Low verbal immediacy, cheery tone, positive appeal, ambiguous

source

*“Happy baby” Low verbal immediacy,, positive appeal, ambiguous source

*“Good health is priceless” High verbal immediacy, positive appeal, health professional

source

“Live strong, live long!” Low verbal immediacy,, positive appeal, ambiguous source

“Thank you, mama.” Low verbal immediacy, friendly tone, ambiguous source

ART Adherence (Male) “Healthy mama = Healthy baby” Low verbal immediacy, informative tone, emotional appeal,

health professional source

Antenatal Attendance

(Women)

*“This is a reminder that your appointment

is on [date].”

High verbal immediacy (Explicit date) informative tone, health

professional source

*“Happy Baby Talk. [dd/mm/yy]”. High verbal immediacy (Explicit date) informative tone,

emotional appeal, ambiguous source

Antenatal Attendance (Male) *“Your partner’s appointment is on [date]...attend

with her if you can”

High verbal immediacy (Explicit date) informative/instructive

tone, health professional source

*“Father of the coming baby [date]” High verbal immediacy (Explicit date) informative tone,

ambiguous source

*“Help her help the baby! [date]” High verbal immediacy (Explicit date) urgent tone, emotional

appeal, ambiguous source

Facility-based delivery

(Women and Male)

*“The baby will be born this week, start

panning early [date]”

High verbal immediacy, informative/instructive tone, health

professional source

“Little by little fills the container/pot” Low verbal immediacy, positive appeal, ambiguous source

“Investment does not rotten/get spoiled” Low verbal immediacy, serious tone, ambiguous source

All messages presented to participants in both English and Swahili.

Messages preferred by women are in Bold face font, while content preferred by male

partners are noted with a “*”

Mabachi et al. BMC Public Health (2021) 21:1491 Page 3 of 10

Female FGD’s were designed to help participants iden-

tify message features that were acceptable and would en-

courage processing, while male FGD elicited feedback

on male partner involvement in PMTCT/EID and SMS

content to encourage partner support pre- and post-

partum. During FGD’s, facilitators first presented partici-

pants with example motivational messages designed to

support appointment adherence, medication adherence ,

and a hospital-based delivery to elicit participant feed-

back. This was done to remove the pressure on partici-

pants to develop their own messages and to engende r a

collaborative environment. Messages were provided in

both Kiswahili and English with the understanding that

what is said in one language may sound very different

once translated. We then reviewed each message asking

participants to assist us in refining word choice, length

of message, and ideal timing and frequency of messages

for each targeted behavior. Once participants were feel-

ing more comfortable with each other and the purpose

of the messag es, we broke them into smaller groups to

generate ideas for new message content – or modify

existing message content - that they would find most

motivating. We reconvened as a full group to discuss

new ideas and reach consensus on the strongest messa-

ging for each targeted behavior. Concerns regarding po-

tential unintentional disclosure of HIV status or other

unintended consequences (e.g. partner suspicion of

source of message) through routine text messages were

explored for each specific message, recognizing preg-

nancy can be a particularly vulnerable period.

Analysis

All interviews were audio recorded, translated and tran-

scribed and an initial codebook was developed. A the-

matic analysis approach was be used to analyze both

focus group and key informant interviews Transcripts

were coded independently using Excel by two study

team members for a priori and emergent themes. Tran-

script coding was an iterative process with cross-

questioning and critique between the coders. A final

codebook included themes that emerged within the prin-

ciples of message design (verbal immediacy, message

source, tone, appeal/incentive, length, frequency, timing,

visuals and language), as well as factors that may encour-

age or hinder active processing. Exemplars for each

theme were noted as well as the frequency and distribu-

tion of themes within the larger topic areas.

Results

Overall, both women and their male partners anticipated

high acceptability of text messages to support adherence,

appointment attendance, and facility delivery. Further-

more, the desire to include their male partner or another

family member in text messages regarding their care was

high among pregnant and postnatal women who had

disclosed their HIV status. Over half of female partici-

pants described existing support and engagement from

male partners. Likewise, nearly all male partners indi-

cated willingness to receive text messages to support

their pregnant partners’ PMTCT engagement and medi-

cation adherence. Of note, although sample messages

were provided to participants in both English and Kiswa-

hili, there was no clear consensus regarding language

preferences, with some focus groups preferring Kiswahili

over English, based on regional and individual linguistic

differences and literacy levels:

Because if I say I want Swahili and I am not conver-

sant with Swahili, what will I do? Or I say I want

English and the next person can’t understand. Let

them come and we are given options which ones we

want. (Male Partner: RV).

Text messages to support ART adherence

While some participants described other mechanisms

for remembering tim ely ART consumption (prompts via

routines, family members, and phone alarms), and most

indicated they usually took their ART medication on

time, skipping doses or taking medications late was re-

ported as a common challenge, either due to forgetful-

ness, fear of disclosure, or other situational challenges:

Maybe us with babies sometimes you may get your-

self busy … You find that the way you were busy you

wake up and you have this and this and this to han-

dle, before you know it time [for taking medication]

is up” (Postnatal Mom: C)

In this context, text messages could provide an add-

itional prompt for medication adherence, indeed , partici-

pants commented as much, “ Even though I always

remember but that [the message] will remind me more”

(Postnatal Mom: W).

Supporting ART adherence: preferred message content

features

Although preferences varied by participant and group,

the most popular message across focus groups- “Friendly

reminder: Hi it’s that time again ” was short in length,

cheery in tone, positive in appeal, neutral in its verbal

immediacy, contained a message visual, and could be

from a friend. One participant commented that they

liked the greeting as it seemed like a normal message to

receive, “I feel [it] is good because at least someone will

see maybe it’s your friend who is greeting you” (Prenatal

Mom: C). Similarly, “Thank you, mama” was also popu-

lar among participants for its low immediacy (neutrality).

Mabachi et al. BMC Public Health (2021) 21:1491 Page 4 of 10

Only a few participants indicated strong preferences for

more direct health-focused messages such as “G ood

health is priceless” and “Live strong, live long.”

Male partner focus groups were provided the same

messages with one modification: “Mama mwenye afya

njema = mtoto mwenye afya” (“Healthy mama=Healthy

baby”) as a prompt to support their partners. Like the

women, they responded favorably to the low immediacy,

friendly features of, “Friendly reminder: Hi it’s that time

again ” with one participant highlighting the indirect

nature of the message, “You see, we remind each other

about [taking medication], and it [the message] has

nothing to do with medication … so I am still on [like]

that one” (Male Partner: C). However, unlike the

women, male partners were receptive to messages such

as: the “healthy mother, healthy baby” and “good health

is priceless” that had greater verbal immediacy (direct),

were informative in tone, had emotion al appeal and

could potentially be from a clinical source As one part-

ner commented, “when she knows why she needs to take

drugs, she will know the importance of the baby taking

drugs and they will be health y” (Male Partner: RV). An-

other part icipant said:

According to that one, good health does not go to

waste. That is a message you see, you will under-

stand fast. Because good health, it’s not just those

who have this condition … everyone deserves good

health. So when you see that message, you will know

it’s time to go take medication. (Male Partner: C)

Supporting ART adherence: confidentiality through low

verbal immediacy

For messages supporting adherence, confidentiality was

a key consideration across all focus groups, participants

responded positively to erring towards messages low in

verbal immediacy and ambiguous in source. That is,

messages that were indirect and neutral in content so

that others using the same phone would not be able to

understand the purpose of the message, “[the message

content] we have chosen no one will know what they

are, it’s only us” (Prenatal Moms: W).

Regardless of their personal HIV disclosure status,

most participants indicated that messages should be tai-

lored to those who had not disclosed to reduce risk, ra-

ther than creating two separate sets of messages

differentiated by disclosure status, “the one who has not

disclosed maybe is the one if she gets a different message

it might bring problem. So if it is one [message] it also

gives the sender an easy work” (Pre and Postnatal

Moms: C).

Participants indicated that if messages were too vague,

they could be misinterpreted raising the risk of jealousy

and suspicion among intimate partners possibly leading

to domestic violence or abandonment. In the context of

partners being unaware of the purpose of the text mes-

sages, some participants raised concerns about the use

of certain words such as “baby”, “they will ask you who

is calling you baby” (Prenatal Mom: W); emojis, “they

will still ask you who is sending you [a] flower on

phone” (Prenatal Mom: W; and greetings, “Or if you

greet me and say hello, isn’t it a must he’ll [male part-

ner] follow that number and ask, ‘And who is this and

this number has no name?’…Now this man will bring

trouble.” (Pre and Postnatal Moms: C).

Supporting ART adherence: message timing and frequency

Preferences for the timing and frequency of adherence-

related text messages varied. However, many participants

preferred to receive messages twice a day (morning and

evening), to correspond with their scheduled medication

times, “So when I receive the SMS in the morning, I just

know time to swallow medicine has come. Even in the

evening when I’m sent, I just know my time has come”

(Postnatal Moms: W). Given that “everyone has their

own time for swallowing medicine,” some participants

indicated wanting to receive a text that was tailored to

their schedule indicating text messages should be sent

shortly before the scheduled time, with preferred inter-

vals ranging from 2 to 5 min in advance, “I always swal-

low at 8 night and 8 morning, so that time, or one

minute to 8 or two minutes like this” (Pre and Postnatal

Moms: C).

Some men and women indicated that over time “they

will get tired” or irritated by text messages sent more

than once a day (Prenatal Moms: W). Instead, those

wanting only daily reminders preferred text messages

sent during the time of day when they were more likely

to forget. Finally, some participants expressed worry that

text messages, especially frequent text messages corre-

sponding to each scheduled dose, would compound an

overreliance on phones for adherence, rather than fos-

tering self-reliance:

Even if it is good and I see the notion is good but it

comes with negative effects. Someone can over rely

on that message to come. So they can say they didn’t

receive the message so they did not take their drugs

… it is not all the time the phone will be charged. It

can get lost or get spoilt, how will they get this mes-

sage?... So what happens? Instead of helping, you

have brought more problems.” (Male Partner: RV)

Given the range of preferences for adherence timing and

frequency, most participants agreed that the ability to

customize frequency was important, so that individuals

could select the frequency based on their needs and

preferences.

Mabachi et al. BMC Public Health (2021) 21:1491 Page 5 of 10

Text messages to support appointment antenatal clinic

(ANC) attendance

Participants found text messages to support clinic at-

tendance as acceptable enhancements to existing mecha-

nisms for remembering ANC appointments. Participants

described relying on clinic cards, phone calls from pro-

viders, and dwindling ART supplies in need of refilling,

as cues to action for appointment attendance. However,

text messages would serve as confirmation of the sched-

uled date, “sometimes you can look at that card and

realize you looked at the date wrongly” or ext ra follow

up for those with poor adherence, “it’s not easy you for-

get because the medicine itself reminds you [to attend

clinic for medication refills]. Maybe now you don’t fol-

low your own schedule of swallowing medicine. That’s

when you can forget [clinic appointments]” (Prenatal

Moms: C). Male part ners were open to the idea of re-

ceiving reminders to support their pregnant partners, “It

helps because there is forgetting, so that reminder is

great.” (Male Partner: W) Even those who were hesitant

to receive more frequent texts to support adherence

were open to the idea of receiving appointment re-

minders, “Appointments [text messages] are fine because

they come after a month or so, I would like that for my

wife.” (Male Partner: W).

ANC appointment adherence: message content preferences

There was no clear consensus on which appointment re-

minder messag es were preferred. Many participants

responded favorably to messages with high verbal imme-

diacy preferring direct appointment reminders and refer-

ences to the baby - “I would pick the [“Happy baby

talk”] one because it has mentioned babies there.” (Pre

and Postnatal Moms: C). Some female participants indi-

cated they would like to receive a message with a greet-

ing and the appointment date. Unlike for adherence text

messages, where confidentiality concerns were promin-

ent, women were comfortable with the clin ic as the ex-

plicit message source given that it would be public

knowledge that recipients were pregnant and texts dis-

cussing antenatal care or facility-based delivery would

not lead to unintentional disclosure, “so [messages men-

tioning] coming for clinic is not bad … because you

could be going for clinic for babies … as long as you

don’t mention which clinic.” (Prenatal Moms: W).

As with the women, male partners responded favor-

ably to both the direct appointment reminder message

and to the other sample messages, finding the specific

mention of “baby” a positive emotional message appea l

to their role as fathe rs to be particularly motivational. In

response to the “help her help the baby” message, one

male participant said, “that is most important. Because

our main job is to protect the unborn child , so if we

don’t remind her it will be doom” (Male Partner: W).

Responding to the “father of the coming baby [date]”

message, another said, “when you are told you have one

that is coming, you must start preparing, there is some-

thing you are waiting for, and when you are expecting

something, the heart beats fast.” (Male Partner: C).

Some male partners highlighted the importance of en-

suring that text messages included accurate appointment

dates to avoid additional burden on women given the

challenges inherent in clinic attendance, “This [is] be-

cause if she comes, she should not be tol d today was not

your appointment day” (Male Partner: RV). One male

partner also indicated that he would prefer to receive ap-

pointment reminders in the evening, when he would be

most likely to di scuss the text with his pregnant partner,

“That is best to come at night, around 7 when we are all

at home, not when I leave” (Male Partner: W).

Text messages to support facility based delivery

Many participants recognized the importance of a

facility-based delivery to minimize the risk of HIV trans-

mission to the infant during the delivery and early post-

natal (prompt initiation of infant ART prophylaxis after

delivery and linkage to EID services).

Participants discussed the need to prepare in advance

to ensure a facility delivery. As such, many participants

thought a reminder to prepare prior to delivery would

be helpful, especially as the due date approached, “Some-

times life becomes so hard you even forget what EDD

(estimated due date) is.” However, one participa nt indi-

cated not wanting to receive SMS for delivery prepar-

ation for herself or her partner, because she felt it

wouldn’t be needed, “It’s something you just know you

will do, and if it’s your husband he’s organizing himself

and he knows his wife is pregnant” (Pregnant Mom: W).

Another woman thought that unengaged partners were

likely to ignore the messages, “If it’s someone who is not

responsible, even if you send him texts, you remind him,

in words, he’ll not do” (Pregnant Mom: C). However,

one male partner thought text messages for delivery

would be received favorably, even by men who would

not normally like to receive messages, “There are some

messages some men might refuse, and there are import-

ant ones. Something that is important to you and your

family you will accept, such as it’s time to give birth. If

you find a message, that your wife is due to birth, you

will find someone to take you to the hospital, which is

also important.” (Male Partner: C).

Facility based delivery: message content preferences

While there was no clear consensus regarding message

preference, feedback highlighted a preference for high

immediacy, with more direct mention of the baby/deliv-

ery. Male partners preferred the first message (“the baby

will be born this week …” ) over the second, given that it

Mabachi et al. BMC Public Health (2021) 21:1491 Page 6 of 10

was more specific, “Number one, because “a little a little”

is used in many things” (Male Partner: C).

Facility based delivery: message timing and frequency

Most pregnant and postnatal women indicated that they

would like to receive reminders to prepare for delivery

in the month prior to delivery, so that the message

would come in time to prepare, but not too early so as

to be disregarded, “You know again when you are told

early you’ll wait” (Pregnant and New Moms: RV). Many

respondents wanted to receive a text message 1 month

before their EDD, while others wanted a reminder 2

weeks and 1 week prior to EDD, with several indicating

they would like to receive messages as frequently as once

a week, especially in the last month of their pregnancy:

Because in the book normally we are written for

EDD which is the date for delivery, but obviously,

that’s not the day we are supposed to read [deliver]

… So it’s good whoever is sending us message to do it

two weeks before … (Prenatal Moms: W)

However, some women wanted to receive text messages

even earlier, at six or seven-month gestation to account

for premature deliveries and, “because that’s when most

people have complications” (Postnatal Moms: W). While

male partners thought their pregnant partners could be

sent more frequent messages regarding delivery prepara-

tions, a few indicated they would only want to receive

text messag es for themselves once or twice.

Discussion

This formative study to develop optimal text messaging

features to support PMTCT participation and retention

was part of a system-level, web-based patient tracking

intervention development study [11]. Previous qualita-

tive studies have explored the acceptability and utility of

using SMS messaging and understanding content prefer-

ence to encourage ART adherence [19–21] and engaging

in the PMTCT cascade of care [5, 7, 10, 22] In this

study, we sought to better understand SMS messages

that would be acceptable and encourage HIV+ pre and

postnatal women and the ir male partners to engage in

the PMTCT cascade of care including: 1) Antenatal ap-

pointment adherence, 2) ART adherence, and 3) a

hospital-based delivery.

As with previou s studies, participants were open to re-

ceiving text messages to help them better participate in

the PMTCT cascade of care. Importantly, HIV+ women

who participated in the FGD’s and had disclosed their

HIV status were open to messages being sent to their

male partners and conversely, partners who were already

engaged in their pregnant partner’s PMTCT care were

happy to be included in the communication. This is

encouraging given that research indicates increased

PMTCT engagement when male partners participate

and provide social support [23–27].

Regarding reminders for ART medication, individual

preferences and confidentiality remained critical prior-

ities for participants. Due to confidentiality concerns and

varying levels of disclosure with partners and family

members, participants preferred that adherence mes-

sages wer e short in length, low in verbal immediacy i.e.

neutral/ambiguous, cheery in tone, emotionally/positive

in appeal and from a non-clinical source. Message con-

tent customization has been proposed as a way to ad-

dress confidentiality issues; however, unlike previous

literature this particular group of participants were more

concerned with low verbal immediacy of the message,

indicating [10] a preference that messages accomm odate

those who had not disclosed, rather than creating several

custom messages. Participants also cautioned that al-

though having an ambiguous message source can help

maintain confidentiality for those who had not disclosed,

it may inadvertently raise a male partner ’s suspicions

and jealousy regarding the message source and purpose,

potentially causing an unsafe home environment. Finally,

participants preferred the frequency and timing of medi-

cation reminders be once or twice a day: morning and

evening, with those with a previously established ART

routine mor e likely to prefer daily messages. Interest-

ingly, a participant expressed that reminders could have

the unintended consequence of creati ng a dependency

on reminders instead of fostering self-reliance in the

eventuality a phone is unavailable.

In regard to encouraging ANC attendance and a hos-

pital delivery, participants were open to messages that

were higher in verbal immediacy, as they felt that health

appointments around pregnancy were less likely to raise

HIV status disclosure concerns. Male partners liked the

explicit reference to the coming baby in the message, as

they saw this emotional appeal as a motivational re-

minder – even for those men who may not otherwise be

engaged in earlier stages of the pregnancy. Overall, par-

ticipants viewed these reminders as a welcome addition

to clinic cards, phone calls from providers, and dwin-

dling ART supplies in need of refilling, as cues to action

for facility attendance.

The feedback and preferences of participants were

used to design the final messages that were integrated

into the web-based tracking intervention, HITSystem 2.0

[11]. To cut through the noise and clutter of other text

messages, HITSystem 2.0 messages overall were de-

signed per participant preferences to have an emotional/

positive appeal, were brief, were low in verbal immediacy

to avoid unintentional disclosure for ART messages and

high in verbal immediacy for appointment and delivery

reminders. Participants were given the option to opt in

Mabachi et al. BMC Public Health (2021) 21:1491 Page 7 of 10

or out of adherence messages, given ongoing concerns

about confidentiality. We stress the importance of ensur-

ing that given the potential for stigma, violence, and

ostracization SMS messages are only sent to participants

who have given their express permission and feel safe re-

ceiving the messages having disclosed to their partners

and/or family. Adherence messages were further cus-

tomized in terms of frequency (with participants able to

select daily, weekly, twice monthly, or monthly mes-

sages) and content (with participants able to select one

of three messages (“ni saa”, “je hujambo”, “je, uhali

gani”), which included the preferred components (“it’s

time” and two friendly greeting options) of the text mes-

sage most preferred by this study’s participants. Given

limitations with the texting platform, the exact timing of

messages could not be customized to align with individ-

ual’s dosing schedules. Appointment reminders were

sent 2 days prior to each scheduled appointment and

contained the text “Tafadhali mama fika kliniki siku ya

[appointment date] kwa ajili ya maudhurio ya ujauzito,

tunatarajia kukuona” (Please return to the clinic on [ap-

pointment date] for pregnancy services. We’ll be happy

to see you! ) Delivery support was sent 4 weeks and 2

weeks before the woman’s EDD and contained the text,

“Tuna furaha sana vile uko karibu kujifungua! Ili mtoto

azaliwe na afya bora kabisa, ni vizuri ujipange kujifun-

gulia hospitalini (We are happy that you are close to de-

livering! For your baby’s best health, it is good to deliver

in the hospital!) Messages for male partners have not yet

been incorporated into the intervention for implementa-

tion and evaluation. Results on the overall satisfaction

with the messages to HIV+ pregnant women will be re-

ported elsewhere in a study satisfaction paper.

Strengths and limitations

This formative study is limited by its relatively small

sample size, with one focus group for each geographic

region of Kenya (Western, Central, Coastal). Focus

group setting can activate participants’ sense of social

desirability, thus affecting their responses. Male partici-

pants were aware of their female partners HIV status

and were engaged in their female partner’s PMTCT care,

thus may not be representative of males less engaged in

their female partner’ s PMTCT care. Yet, it is a strength

that the perspectives of male partners were included, as

this is often missing despite the integral role of male

partners in decision making during pregnancy [5, 23].

Limited demographics on participants were collected,

thus, we are unable to comment on how various socio-

demographic characteristics may impact preferences for

text messages. The qualitative design of the study

allowed for a collaborative process that provided an in-

depth understanding of barriers to PMTCT participa-

tion, message content and design preferences. We also

included women in different stages of their pregnancy

thus eliciting a wide variety of experiences. However, we

believe that the messages developed through this forma-

tive work has the best chance of being acceptable to the

widest audience/all HITSystem parti cipants. This was

the formative part of a larger study and as such did not

require large numbers; however, we recommend that fu-

ture research that focuses on communication strategies

to motivate PMTCT engagement include larger focus

group or interview sample sizes that includes both HIV+

mothers and male partners. We also recommend having

focus groups that include male partners who are not as

engaged in PMTCT care as it may provide insight into

their reasons for minimal engagement as well as the

types of messaging that would be motivating to them.

Recommendations for practice

Given our results we recommend that Kenyan PMTCT

practitioners leverage the use of SMS messaging as a

strategy in motivating cascade of care recommended be-

haviors such as medication adherenc e, ANC appoint-

ment attendance and hospital delivery. SMS messages

can also be used for other specific programmatic goals

such as social support messaging as appropriate. We

stress that use of SMS messaging as a strategy must only

be used with the permission of patients given the poten-

tial for unintentional disclosure with a partner or family

that may lead to undesirable outcomes. For couples who

have disclosed to each other SMS messages can be used

to encourage male partner engagement in the PMTCT

cascade of care as well as engender partner informa-

tional and emotional support that is crucial at this im-

portant time. To optimize engagement and avoid

message habituation, we encourage PMTCT providers to

seek the input of mothers, their partners and providers

in creating messag es that are the most motivating to

them. Seeking input will also help account for contex tual

factors including geographical, language and other com-

munity differences.

Conclusion

Our findings indicate that utilizing text messages to sup-

port engagement in PMTCT care is acceptable among

women living with HIV and their partners. Engaging end

users in the development of message content for key

PMTCT services can optimize relevance and ensure ac-

ceptability of SMS.

Abbreviations

PMTCT: Prevention of mother-to-child HIV transmission; EID: Early infant

diagnosis; HITS: HIV infant tracking system; ART: Anti-retroviral treatment;

SMS: Short message service; ANC: Antenatal clinic; FGD’s: Focus group

discussions

Mabachi et al. BMC Public Health (2021) 21:1491 Page 8 of 10

Supplementary Information

The online version contains supplementary material available at https://doi.

org/10.1186/s12889-021-11444-x.

Additional file 1.

Acknowledgements

The Authors would like to acknowledge the hospital staff and research

project coordinators at the hospitals in the three sites for their dedication

and hard work during the study. We also thank the participants who

graciously gave their time and insights.

Authors’ contributions

NM – Substantially contributed to the design of the work, data collection,

data analysis, and drafting, writing and editing of the manuscript. MB and

CW – Substantially contributed to the design of the work, data analysis, and

writing of the drafting, writing and editing of manuscript.

MM and DO Substantially contributed to the design of the work, data

collection, data translation and editing of the manuscript. KG- Substantially

contributed to the design of the work, writing and editing of the

manuscript. SFK and BG - Substantially contributed to the design of the work

and editing of the manuscript. Authors have read and approved the final

version.

Funding

This work is supported by NIH R34MH107337. The content is solely the

responsibility of the authors and does not necessarily represent the official

views of the National Institutes of Health.

Availability of data and materials

The data that support the findings of this study are available on request

from the corresponding author [NM]. The data are not publicly available as

they may contain information that could compromise research participant

privacy/consent.

Declarations

Ethics approval and consent to psrticipate

All procedures performed in studies involving human subjects were in

accordance with the ethical standards of the institutional and/or national

and country specific research committee and with the 1964 Helsinki

declaration and its later amendments or comparable ethical standards.

Written informed consent was obtained from all individual participants.

Ethics committees that provided approval include: The University of Kansas

human subjects review board and the Kenya Medical Research Institute

(KEMRI) Ethical Review Committee.

Consent for publication

Not applicable.

Competing interests

No potential conflicts exist for all authors.

Author details

Department of Family Medicine, University of Kansas Medical Center,

Mailstop 3064, 4125 Rainbow Blvd., Kansas City, KS 66160, USA.

Children’s

Mercy Hospitals and Clinics, Health Services and Outcomes Research, Kansas

City, MO, USA.

Global Health Innovations (GHI), Nairobi, Kenya.

Kenya

Medical Resear ch Institute (KEMRI), Nairobi, Kenya.

Global Health Innovations

(GHI), Dallas, Texas, USA.

Received: 22 June 2020 Accepted: 1 July 2021

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