title: Developing content for a mHealth intervention to promote postpartum retention in prevention of mother-to-child HIV transmission programs and early infant diagnosis of HIV: a qualitative study.
abstract: BACKGROUND
  Maternal attendance at postnatal clinic visits and timely diagnosis of infant HIV infection are important steps for prevention of mother-to-child transmission (PMTCT) of HIV. We aimed to use theory-informed methods to develop text messages targeted at facilitating these steps.
  
  
  METHODS
  We conducted five focus group discussions with health workers and women attending antenatal, postnatal, and PMTCT clinics to explore aspects of women's engagement in postnatal HIV care and infant testing. Discussion topics were informed by constructs of the Health Belief Model (HBM) and prior empirical research. Qualitative data were coded and analyzed according to the construct of the HBM to which they related. Themes were extracted and used to draft intervention messages. We carried out two stages of further messaging development: messages were presented in a follow-up focus group in order to develop optimal phrasing in local languages. We then further refined the messages, pretested them in individual cognitive interviews with selected health workers, and finalized the messages for the intervention.
  
  
  RESULTS
  Findings indicated that brief, personalized, caring, polite, encouraging, and educational text messages would facilitate women bringing their children to clinic after delivery, suggesting that text messages may serve as an important "cue to action." Participants emphasized that messages should not mention HIV due to fear of HIV testing and disclosure. Participants also noted that text messages could capitalize on women's motivation to attend clinic for childhood immunizations.
  
  
  CONCLUSIONS
  Applying a multi-stage content development approach to crafting text messages--informed by behavioral theory--resulted in message content that was consistent across different focus groups. This approach could help answer "why" and "how" text messaging may be a useful tool to support maternal and child health. We are evaluating the effect of these messages on improving postpartum PMTCT retention and infant HIV testing in a randomized trial.
authors.affiliation: Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya; Department of Epidemiology, University of Washington, Seattle, Washington, United States of America.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Odeny
authors.affiliation: School of Medicine, University of Washington, Seattle, Washington, United States of America.
authors.forename: Maya
authors.initials: M
authors.lastname: Newman
authors.affiliation: Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya; Department of Global Health, University of Washington, Seattle, Washington, United States of America; Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bukusi
authors.affiliation: Department of Epidemiology, University of Washington, Seattle, Washington, United States of America; Department of Global Health, University of Washington, Seattle, Washington, United States of America; Department of Medicine, University of Washington, Seattle, Washington, United States of America; Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya.
authors.forename: R Scott
authors.initials: RS
authors.lastname: McClelland
authors.affiliation: Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Craig R
authors.initials: CR
authors.lastname: Cohen
authors.affiliation: Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America; Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Carol S
authors.initials: CS
authors.lastname: Camlin
mesh_terms: D000328:Adult; D005239:Fear; D005260:Female; D017144:Focus Groups; D015658:HIV Infections / Q000175:diagnosis* / Q000517:prevention & control* / Q000635:transmission; D007722:Health Knowledge, Attitudes, Practice; D006287:Health Planning Guidelines; D006801:Humans; D007223:Infant; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D049590:Postpartum Period; D011247:Pregnancy; D036301:Qualitative Research; D017216:Telemedicine; D060145:Text Messaging