Transitioning a digital health innovation from research to routine practice: Two-way texting for male circumcision follow-up in Zimbabwe

Phiona Marongwe; Beatrice Wasunna; Jacqueline Gavera; Vernon Murenje; Farai Gwenzi; Joseph Hove; Christine Mauhy; Sinokuthemba Xaba; Raymond Mugwanya; Batsirai Makunike-Chikwinya; Tinashe Munyaradzi; Michael Korir; Femi Oni; Antony Khaemba; Mourice Barasa; Marrianne Holec; Vuyelwa Sidile-Chitimbire; Mufuta Tshimanga; Isaac Holeman; Scott Barnhart; Caryl Feldacker

doi:10.1371/journal.pdig.0000066

Transitioning a digital health innovation from research to routine practice: Two-way texting for male circumcision follow-up in Zimbabwe

PLOS Digit Health. 2022 Jun 15;1(6):e0000066. doi: 10.1371/journal.pdig.0000066. eCollection 2022 Jun.

Authors

Phiona Marongwe^{1

2}, Beatrice Wasunna³, Jacqueline Gavera¹, Vernon Murenje¹, Farai Gwenzi¹, Joseph Hove⁴, Christine Mauhy⁵, Sinokuthemba Xaba⁶, Raymond Mugwanya³, Batsirai Makunike-Chikwinya¹, Tinashe Munyaradzi⁵, Michael Korir³, Femi Oni³, Antony Khaemba³, Mourice Barasa³, Marrianne Holec⁷, Vuyelwa Sidile-Chitimbire⁴, Mufuta Tshimanga⁵, Isaac Holeman^{8

9}, Scott Barnhart^{2

7

9}, Caryl Feldacker^{7

9}

Affiliations

¹ Zimbabwe Technical Training and Education Centre for Health (Zim-TTECH), Harare Zimbabwe.
² Department of Global Health, University of Washington, Seattle, Washington, United States of America.
³ Medic, Nairobi, Kenya.
⁴ Zimbabwe Association of Church related Hospitals (ZACH), Harare Zimbabwe.
⁵ Zimbabwe Community Health Intervention Research (ZiCHIRe), Harare Zimbabwe.
⁶ Ministry of Health and Child Care (MoHCC), Harare Zimbabwe.
⁷ International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, Washington, United States of America.
⁸ Medic, San Francisco, California, United States of America.
⁹ School of Medicine, University of Washington, Seattle, Washington, United States of America.

Abstract

Adult medical male circumcision (MC) is safe: global notifiable adverse event (AE) rates average below 2.0%. With Zimbabwe's shortage of health care workers (HCWs) compounded by COVID-19 constraints, two-way text-based (2wT) MC follow-up may be advantageous over routinely scheduled in-person reviews. A 2019 randomized control trial (RCT) found 2wT to be safe and efficient for MC follow-up. As few digital health interventions successfully transition from RCT to scale, we detail the 2wT scale-up approach from RCT to routine MC practice comparing MC safety and efficiency outcomes. After the RCT, 2wT transitioned from a site-based (centralized) system to hub-and-spoke model for scale-up where one nurse triaged all 2wT patients, referring patients in need to their local clinic. No post-operative visits were required with 2wT. Routine patients were expected to attend at least one post-operative review. We compare 1) AEs and in-person visits between 2wT men from RCT and routine MC service delivery; and 2) 2wT-based and routine follow-up among adults during the 2wT scale-up period, January to October 2021. During scale-up period, 5084 of 17417 adult MC patients (29%) opted into 2wT. Of the 5084, 0.08% (95% CI: 0.03, 2.0) had an AE and 71.0% (95% CI: 69.7, 72.2) responded to ≥1 daily SMS, a significant decrease from the 1.9% AE rate (95% CI: 0.7, 3.6; p<0.001) and 92.5% response rate (95% CI: 89.0, 94.6; p<0.001) from 2wT RCT men. During scale-up, AE rates did not differ between routine (0.03%; 95% CI: 0.02, 0.08) and 2wT (p = 0.248) groups. Of 5084 2wT men, 630 (12.4%) received telehealth reassurance, wound care reminders, and hygiene advice via 2wT; 64 (19.7%) were referred for care of which 50% had visits. Similar to RCT outcomes, routine 2wT was safe and provided clear efficiency advantages over in-person follow-up. 2wT reduced unnecessary patient-provider contact for COVID-19 infection prevention. Rural network coverage, provider hesitancy, and the slow pace of MC guideline changes slowed 2wT expansion. However, immediate 2wT benefits for MC programs and potential benefits of 2wT-based telehealth for other health contexts outweigh limitations.

Copyright: © 2022 Marongwe et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Grants and funding

The ZAZIC VMMC program and its 2wT component that provided data for these analyses was supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) (https://www.state.gov/pepfar/) through the US Centers for Disease Control and Prevention (CDC) (https://www.cdc.gov), under the terms of CDC cooperative NU2GGH002116 to the International Training and Education Center for Health and the University of Washington, Principal Investigator, SB. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.