Positionality and trustworthiness.

The lead interviewer is not employed by Zim-TTECH, nor any partner organization, but is affiliated with the University of Washington Department of Global Health, a funder of the 2wT program in Zimbabwe. This quality improvement study received no specific funding. This may have impacted how interviewees responded to questions. The remaining authors are either from, or work closely with, the Zim-TTECH organization which may have influenced their interpretation of the responses. Another factor is that all interviews took place virtually rather than in-person due to COVID-19 travel restrictions. Interviewees may have been more or less comfortable with virtual interviews, impacting their responses. All researchers were attentive to iterative process evaluations of trustworthiness [25], assessing and strengthening the study’s methodological rigor, transparency, and inclusion across data collection, analysis, and results reporting phases.

2wT improves quality of client follow-up care.

Interviewees overwhelmingly reported that the 2wT program is largely a success, as one interviewee remarked, “we have a lot to really celebrate.” [IDI-15] HCW interviewees noted advantages for client care, since now “[clients] have the motivation and are willing to respond…People are interested in their own health and are willing to communicate directly with the two-way texting nurse.” [IDI-01] HCWs expressed that 2wT increases close post-operative monitoring and improves identification of Aes over in-person visits:

“[2wT] has increased the follow-up rate. It also has improved adverse event surveillance. I think that close interaction with clients would always [allow us] to know if there is an adverse event.” [IDI-07]

2wT also appears to improve follow-up data quality since the system both stores interactive messages and alerts nurses for timely documentation of referrals to care outcomes. Instead of clerks transcribing clinical notes from multiple sources, the 2wT nurse completes reporting. “With two-way texting…it’s the service provider who is in contact with the client. [They are] getting first-hand information and entering the data.” [IDI-09]

Continuous, on-the-job 2wT training is effective for 2wT scale-up support.

Interviewees described the 2wT curriculum content of in-class role plays, 2wT-based practical exercises, and on-the-job training, as simple and useful. “The training has been quite successful in giving all the information within a day, and [HCWs are] able to use it soon afterward.” [IDI-04] The one-day format caused little disruption to the clinicians’ duties, and the practical training enhanced learning the content. One interviewee noted, “hands-on [training] sped up the learning process, and also improved the buy-in and appreciation of the technology.” [IDI-01] When COVID-19 restrictions led to a temporary change to virtual training, HCWs missed on-site support and repetitive practice. Still, virtual training did have upsides, because “all players are there, everyone is there, they exchange ideas. [Training by] visiting HCWs in their facilities takes time and people don’t have one platform to exchange ideas.” [IDI-08] Interviewees remarked on the importance of continuous trainings, and voiced that the role of the Hub Nurse should “[provide] continuous mentorship support” [IDI-08]

2wT saves provider, client, and program costs, creating enthusiasm for continued scale-up.

Interviewees reported that the 2wT program contributed to resource savings, both financial and human. For HCWs, 2wT saved travel time over in-person follow-up, leaving time for demand creation or other health services. On the program level, 2wT also decreases costs, “because for you to go for follow-ups, you need a vehicle, you need to support the service providers…it involves a lot of personnel. But if there’s someone just sitting there and in charge of the clients [via 2wT], it’s a lot easier.” [IDI-02] Respondents noted that they believe that 2wT largely eliminates the need for clients to travel and take time off work. “Two-way texting came at a time when clients, especially adult males, were not willing to have the commitments to meet the service delivery teams and have them conduct reviews. So, I think it’s popular. It’s very convenient for clients.” [IDI-07] Several HCWs confirmed that client demand for 2wT has grown, so that “clients will just come in and they’ll ask, ‘Oh, I want to be part of the clients that will be texting back and forth. I won’t be able to come [into the clinic] because I’ll be at work.” [IDI-03]

The 2wT app is easy to use, making it attractive for healthcare workers.

For HCWs, most interviewees identified the ease and usability of the 2wT app as a major strength of the program: “It’s just very simple steps to follow.…. It’s actually very friendly for the healthcare staff.” [IDI-03] HCWs also remarked on the multi-lingual 2wT system that reaches clients in their preferred language. HCWs felt the system is easy for clients to use, regardless of their education. “The [clients] easily understand it, even those who we were not sure would be able to use it because of literacy levels.” [IDI-06]. The simplicity of the app for HCW and client users was attributed to the 2wT co-design approach. A respondent from technology partner, Medic Mobile, noted: “We designed a system with our users, for our users…. That’s something that I would say I’m really proud of, just from the start: making sure that the digital health intervention really resonates with its users and that it’s really solving for their pain points.” [IDI-15]. Interviewees also appreciated ongoing 2wT adaptation and revision based on ongoing user feedback. For example, to improve messaging speed, Medic Mobile developers leveraged the Community Health Toolkit (CHT) integration with another open-source tool, RapidPro, “to allow more [2wT] messages to be sent out at a given time. I think that’s probably one of the big things…that might be going well with the scale-up.” [IDI-16]. Frontline HCW appreciated this consistent effort to simplify and improve their own user experience, that of their VMMC clients.

2wT is widely accepted by clients, communities and MoHCC.

Most interviewees’ perception was that the 2wT program was generally well received by clients and HCWs alike, resulting in a high program uptake. “The response rate has been good. Even in areas where there is no good [cellular] network.” [IDI-01] Interviewees identified promotion of the 2wT follow-up method at community and facility levels as a program strength, including distribution of 2wT branded masks and hats, sensitization on 2wT during community health talks, 2wT training for village health workers, and VMMC outreach to adult working men highlighting availability of 2wT-based follow-up. As a result, one interviewee stated that “two-way texting is now a household name.” However, HCWs noted that broad support was not immediate. HCWs initially had their own doubts about client safety and concerns about clients’ digital literacy, but with time, “our population kind of embraced [2wT].” [IDI-01] While success among clients and HCWs was encouraging, respondents were most impressed with MoHCC acceptance. “The fact that the Ministry really appreciated this two-way texting intervention and supported the scale up [is a] huge success.” [IDI-15] Another respondent considered MoHCC partnership as critical for success, noting that “[2wT is] a good innovation [which] is telling policymakers that these [physical] follow-ups are not necessary, and policy should be informed by this finding.” [IDI-02]

Difficult maintaining core numbers of 2wT trained or motivated HCWs at site level.

Multiple respondents reported lack of sufficient trained HCW to support the 2wT program. Although sites had at least one trained staff member, those with only one found that enrolment was disrupted if the trained nurse was not on duty or took a different job. “Once our trained nurses have gone away, we have no one enrolling our clients.” [IDI-04] Multiple partners identified staff shortages due to attrition, or a shortage of trained HCWs at sites, as a constraint to scale-up. However, even with on-site 2wT training, staff must perceive 2wT as part of routine duties, and not as a special or additional task. Multiple interviewees pointed out that some sites had HCWs who appear reticent to use to 2wT since, “in some sites, you would get someone who is not very keen with two-way texting.” [IDI-02]

Persistent technological barriers to sustained 2wT roll-out.

Poor cellular network connectivity and access to devices slow 2wT expansion. Of the 16 program partners interviewed, 13 discussed poor mobile networks as a constraint to scale-up that deprived program partners and clients access to the system. Especially in rural areas, “some of the areas are very remote and network coverage is very poor…It’s difficult to implement when there is no mobile network.” [IDI-07]. Still, urban areas could face power outages that affect network availability. Interviewees also reported that the 2wT app was slow when high volumes of new clients were added. “After a while, the system starts to slow down because of the volume of data on it. [Now], we purge old data from the devices, so the system doesn’t have to filter through so much data before it loads.” [IDI-14] System delays can lead HCWs to enroll clients after hours, causing syncing issues that result in data gaps, or, infrequently, some clients not receiving messages on time or at all.

Clients struggle with 2wT costs and communication.

Interviewees described their observations of client challenges, such as low technology literacy and phone sharing as barriers to scale-up. Some stakeholders felt that clients lacked a phone or shared a phone with others in their household, particularly in rural areas or among minors. IDI-09 commented that, “Most of them share phones with their parents, their siblings, and sometimes you may get responses, not from the client, but from another person.” Multiple interviewees also stated that cost was a potential barrier as clients had to purchase their own airtime for communicating with the nurses via 2wT. “The issue of just the availability of the dollar, to be texting back and forth [is a challenge].” [IDI-03]

Complexity of data management between MoHCC paper forms and 2wT digital database.

To date, MoHCC mandates paper reporting for VMMC procedures, resulting in data duplication for 2wT clients. IDI-02 remarked on “the duplication of the system in the enrollment. Because we have paper-based client intake forms, and we have this two-way texting system, which is collecting the same data.” IDI-03 identified the additional work this created, noting the need “for the hard copy for the circumcision itself. As much as we are going to enter them into the system, we are still going to enter them in another physical form.” Making changes to global or national policies such as discontinuation of paper forms is not simple. “There is not much control in terms of determining the pace of moving things. It’s all reliant on the Ministry of Health.” [IDI-13]

Improve the technology for HCWs and clients.

Several interviewees stated that previous clients should be archived to free the system memory and increase the application speed on HCW devices. Features such as improved data visualization and audible notifications for new messages could promote timely nurse responses. Several interviewees proposed 2wT be delivered on WhatsApp, versus traditional SMS, “because with WhatsApp, [clients] say it’s cheaper, and they no longer communicate using an SMS. [IDI-05] Additionally, multiple interviewees discussed needing system updates to allow multiple clients to enroll with the same phone number or f multiple phone numbers per person, accommodating those with multiple SIM cards. “The platform should allow a number to be entered twice, especially when the surname is the same, to show that these [clients] are related and they’re using the same number.” [IDI-11] Lastly, considerations of improved security, such as two factor authentication for access to 2wT client data were voiced as being needed.

Train, and refresher train, more 2wT staff.

While almost every interviewee stated that the 2wT training was an overall success, some cautioned, “if you are to expand, there is a need to cascade the training down, so that you can also have provincial-based trainers, or district, or even site-based trainers.” [IDI-07] Incorporating the 2wT program training into the standard VMMC training package for all new VMMC staff could also ensure that all MOH service providers become skilled with 2wT: “Because when we, if we, are going into sustainability, that is going to be a huge barrier.” [IDI-11] Lastly, improving the training’s reach by extending 2wT training to community health workers, and offering consistent refresher training, will help fill personnel gaps: “when one [trained healthcare worker] is absent, or unwilling, another can take over.” [IDI-06]

Replace paper with 2wT for all VMMC data.

Duplication of paper and electronic data increases HCW burden, potentially compromising data completeness in either system. "Maybe if we could do away with the paper based and we just go digital, it might improve our adverse event reporting?” [IDI-04] Another interviewee suggested that if all VMMC data were entered into the same system, 2wT enrollments could be automated, and those not enrolled into 2wT could still have their routine VMMC data entered digitally. “Those with phone numbers automatically go into two-way texting. Those without, you have to indicate that they didn’t bring a phone. Electronically moving away from the use of paper [client intake forms].” [IDI-11] Comprehensive electronic VMMC data could ensure data linkage “to other databases that are used by Ministry of Health as well, so that it’s available to a wider group,” [IDI-08], making data more readily available to decision-makers.

Transition 2wT to more MoHCC ownership and integrate 2wT into Zimbabwean e-health.

Several respondents noted a desire to offer 2wT to other VMMC implementing partners and transferring implementation to central MoHCC leadership. 2wT could be “made a national thing, through the Ministry of Health through sensitization…to say, now everybody’s using two-way texting through the Ministry of Health, I think that would improve uptake.” [IDI-04] The open-source (no fee) CHT 2wT software gave respondents optimism for potential MoHCC transition, “because we were worried that if its proprietary software, once the other partners would be off [stop funding 2wT], the Ministry of Health would not be able to sustain its use.” [IDI-13] To support transition, respondents noted that local software engineers from partner organizations and/or MoHCC must be trained to competence and confidence in the CHT, including the 2wT system, and that 2wT would need local server hosting. “Transiting software engineering skills to the local team for 2wT maintenance is a priority for consistently meeting the needs of end users. [IDI15]. Lastly, there is a huge leap between recognizing 2wT benefits and integrating 2wT into MoHCC e-health architecture. “Trying to sell [2wT] to the other people, especially the health informatics department, they appreciate it, but they had huge expectations that two-way texting would seamlessly integrate with all aspects of the electronic health system.” [IDI-01] The pathway forward is neither simple nor straightforward.

Expand 2wT follow-up to other health conditions beyond VMMC.

All respondents noted that 2wT could benefit clients and HCWs beyond VMMC. “There are so many opportunities of which we haven’t done much in terms of demand creation… [2wT] information dissemination, there is a huge gap and opportunity.” [IDI-07] For example, 2wT supported VMMC service delivery during COVID-19 and could be leveraged for subsequent pandemic waves. “Two-way texting has come at the right time, because we are able to review clients without physical reviews… during this outbreak of COVID.” [IDI-05] As COVID-19 wanes, but client demand for improved communication with HCWs grows, interviewees identified areas for 2wT growth. “For example, growth monitoring, HIV care and treatment, immunizations and so on. It will be very useful because it informs the health worker how the client is and will keep the client informed about when to make a certain visit or take drugs.” [IDI-06] Another interviewee suggested that 2wT can provide “follow-up for outpatients with chronic conditions, say the diabetics or hypertensive clients, they can measure their own blood pressure and give feedback via 2wT and avoid unnecessary movements going back to the hospital or clinic.” [IDI-07]