Barriers to acceptance of personal digital assistants for HIV/AIDS data collection in Angola

https://doi.org/10.1016/j.ijmedinf.2011.04.004Get rights and content

Abstract

Purpose

Handheld computers have potential to improve HIV/AIDS programs in healthcare settings in low-resource countries, by improving the speed and accuracy of collecting data. However, the acceptability of the technology (i.e., user attitude and reaction) is critical for its successful implementation. Acceptability is particularly critical for HIV/AIDS behavioral data, as it depends on respondents giving accurate information about a highly sensitive topic – sexual behavior.

Methods

To explore the acceptability of handheld computers for HIV/AIDS data collection and to identify potential barriers to acceptance, five focus groups of 8–10 participants each were conducted in Luanda, Angola. Facilitators presented Palm Tungsten E handhelds to the focus groups, probed participants’ perceptions of the handheld computer, and asked how they felt about disclosing intimate sexual behavior to an interviewer using a handheld computer. Discussions were conducted in Portuguese, the official language of Angola, and audio-taped. They were then transcribed and translated into English for analysis.

Results

In total, 49 people participated in the focus groups. PDAs were understood through the lens of social and cultural beliefs. Themes that emerged were suspicion of outsiders, concern with longevity, views on progress and development, and concern about social status.

Conclusions

The findings from this study suggest that personal and cultural beliefs influence participant acceptance of PDAs in Angola. While PDAs provide great advantages in terms of speed and efficiency of data collection, these barriers, if left unaddressed, may lead to biased reporting of HIV/AIDS risk data. An understanding of the barriers and why they are relevant in Angola may help researchers and practitioners to reduce the impact of these barriers on HIV/AIDS data collection.

Highlights

► We asked Angolans to reflect on storing their HIV risk data on handheld computers. ► Concerns about outsiders, longevity, development, and social status were raised. ► Concerns are rooted in the historical and contemporary context of Angola. ► Prior to electronic data collection, learn and address community's concerns.

Introduction

Information technology has greatly improved health services, particularly in high-income countries such as the United States and in Western Europe. For example, information about prevention and treatment of many diseases is widely available on the World Wide Web [1], [2]. And, electronic medical records are expected to revolutionize the way that healthcare is delivered [3], [4], [5].

However, to date, people in low-resource countries have not received the same benefits from information technology as people in industrialized nations [6], [7], [8]. People in this region do not have the same level of access to technology, due in part to the high cost of the equipment, the lack of equipment and applications that are designed for their context, and unreliable sources of electricity (e.g., [8]).

Handheld computers, for example, personal digital assistants (PDAs), may be one solution that can improve the information flow and quality of health services provided in low-resource countries [9]. A number of data collection and informational applications are now available for PDAs. The touchscreen is easy and intuitive to use, with extra functionality provided through the keypad. PDAs operate on long-lasting rechargeable batteries, and in some cases, may be charged using solar panels. Solar chargers performed well in a large household survey in remote areas of rural Tanzania [10]. In addition, PDAs allow health providers to be more mobile, traveling from clinic to clinic or village to village.

However, the success of using PDAs in low-resource countries depends on the acceptability of the technology (i.e., user attitude and reaction toward the technology). There is growing recognition in the literature that user attitudes are critical to the success of informatics solutions [11], [12], [13].

Acceptability of a technology for data collection is particularly critical for HIV/AIDS prevention researchers and practitioners, because they rely on respondents to give accurate information about a highly sensitive topic – sexual behavior. Studies confirm that people in low-resource countries are concerned about privacy and confidentiality regarding their sexual behavior [14], [15], [16]. Researchers and practitioners who do not adequately demonstrate to respondents that computerized surveys are confidential may not only gather inaccurate data, but also they may become targets of violence [17]. For example, in Mensch et al.’s study, researchers entering rural communities in Kenya to conduct sexual behavior surveys with laptop computers were thought to be government spies. While some research has compared the speed and efficacy of using PDAs for health-related data collection, few studies have addressed the social and cultural factors affecting PDA acceptance [18].

The purpose of this study then was to identify potential barriers to acceptance of PDAs in studies of HIV risk in post-conflict Angola. HIV prevalence in Angola is estimated to be 2.1% [19]. Though the prevalence rate is relatively low compared to neighboring countries, such as Namibia, Zambia, and DR Congo, the end of Angola's 27-year civil war in 2002 has increased population mobility and enabled HIV to spread more quickly through the country. There is a particular urgency for implementing and evaluating HIV prevention programs. Like other sub-Saharan African countries, Angola has much to gain from the successful deployment of PDA-based HIV-related data collection.

To explore the acceptance of PDAs for studies of HIV risk in Angola, we conducted qualitative focus groups with Angolans in the fall of 2005, just a few years after the end of the civil war. Participants were recruited across the range of social and economic strata. We presented PDAs to focus group participants and discussed their concerns with disclosing sexual behaviors to interviewers using a PDA.

Section snippets

Sampling and recruitment

Participants were men and women, between the ages of 18 and 55, who lived or worked in Luanda, Angola. They were recruited via flyers and face-to-face invitations. To gain a broad representation, participants were recruited from three populations of varying socioeconomic levels: patrons of cybercafés in the Maianga neighborhood, where residents are primarily of higher education and higher income; passers-by of a local youth center in the Bairro Pedelé neighborhood, where residents are of

Results

Table 1 displays the participant characteristics from each of the five focus groups whose transcripts were analyzed. There were 49 focus group participants, 30 of whom were men and 19 of whom were women. The average age was 25.5 years, and the average number of completed years of education was 8.9. As expected, the participants from the cybercafés were more educated than participants from the neighborhood, and participants from the neighborhood were, in turn, more educated than participants

Discussion

Using qualitative data, we identified four possible barriers to Angolans accepting the use of PDAs for HIV/AIDS risk behavior data collection: suspicion of outsiders, concern with longevity, views on progress and development, and concern about social status. While PDAs provide great advantages in terms of speed and efficiency of data collection, these barriers, if left unaddressed, may lead to biased reporting of HIV/AIDS risk data (see [24] for an example). Biased reporting, in turn, will

Authors’ contributions

Karen G. Cheng contributed to the study design, acquisition of data, analysis and interpretation, drafts and revisions of article, final approval for submission. Francisco Ernesto contributed to the study design, analysis and interpretation, drafts and revisions of article, final approval for submission. Ricardo Ovalle-Bahamón contributed to the study design, acquisition of data, analysis and interpretation, drafts and revisions of article, final approval for submission. Khai N. Truong

Conflicts of interest statement

Karen G. Cheng and Ricardo Ovalle-Bahamón received a small percentage (10% or less) of their salaries from this pilot grant.

Acknowledgements

We would like to thank João Domingos Pinto, Edna Tchivandja, Magna Napoleão, and Salvador Sebastão for their assistance in facilitating the focus groups and transcribing the discussions. We would also like to thank Daniel Ortiz, Karen Coller, Yuri Sebastião, Gillian Hayes, and Eric Bing for helpful comments on earlier drafts of this paper. This research was funded by a pilot grant from the Center for HIV Identification, Prevention and Treatment Services (NIMH P-30-MH58107). The funders were not

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