Klabbers Robin E, Feldacker Caryl, Huwa Jacqueline, Kiruthu-Kamamia Christine, Thawani Agness, Tweya Hannock
Department of Global Health, University of Washington, Seattle, WA, USA.
Department of Emergency Medicine, University of Washington, Seattle, WA, USA.
Implement Sci. 2025 Jan 22;20(1):6. doi: 10.1186/s13012-025-01418-7.
While key to interpreting findings and assessing generalizability, implementation fidelity is underreported in mobile health (mHealth) literature. We evaluated implementation fidelity of an opt-in, hybrid, two-way texting (2wT) intervention previously demonstrated to improve 12-month retention on antiretroviral therapy (ART) among people living with HIV (PLHIV) in a quasi-experimental study in Lilongwe, Malawi.
Short message service (SMS) data and ART refill visit records were used to evaluate adherence to 2wT content, frequency and duration through the lens of the Conceptual Framework for Implementation Fidelity. Message delivery and 2wT participant interactions were considered across four core 2wT components: 1) weekly motivational SMS messages; 2) proactive SMS appointment reminders; 3) SMS reminders after missed appointments; and 4) interactive messaging with 2wT staff about transfers and appointment rescheduling. Using mixed-effects logistic regression models adjusted for participant demographics, we examined the effect of core 2wT component fidelity on a) on-time appointment attendance and b) timely return to care after a missed appointment, presenting adjusted odds ratios (aORs) and 95% confidence intervals (CIs).
The 468 2wT participants had a median of 52 study weeks (interquartile range [IQR] 34 - 52) with 6 ART appointments (IQR 4-7) of which 2 (IQR 1 - 3) were missed. On average, participants received a motivation message for 75% (IQR 56%-83%) of enrolled weeks, a reminder before 83% (IQR 67%-100%) of appointments, and after 67% (IQR 0%-100%) of missed appointments. Participants reported 9 transfers and rescheduled 46 appointments through 2wT prompts; 196 appointments were changed via unprompted interaction. Participants with 10% higher expected motivation message delivery were more likely to attend clinic appointments on time (aOR: 1.08; 95%CI: 1.01 - 1.16, p = 0.03). Receiving and responding to an appointment reminder in any way were also associated with increased on-time appointment attendance (aOR: 1.35; 95%CI: 1.03 - 1.79, p = 0.03 and aOR: 1.47, 95%CI: 1.16 - 1.87, p = 0.001, respectively). No associations were found for 2wT messages and timely return to care following a missed appointment.
Greater 2wT implementation fidelity was associated with improved care outcomes. Although implementation fidelity monitoring of mHealth interventions is complex, it should be integrated into study design.
虽然实施保真度是解释研究结果和评估普遍性的关键，但在移动健康（mHealth）文献中对其报道不足。我们评估了一项选择加入的混合式双向短信（2wT）干预措施的实施保真度，该干预措施在马拉维利隆圭的一项准实验研究中，先前已证明可提高艾滋病毒感染者（PLHIV）接受抗逆转录病毒治疗（ART）12个月的留存率。
通过实施保真度概念框架，使用短信服务（SMS）数据和ART药物补充就诊记录来评估对2wT内容、频率和持续时间的依从性。在2wT的四个核心组成部分中考虑了短信发送和2wT参与者的互动：1）每周一次的激励性短信；2）主动发送的短信预约提醒；3）错过预约后的短信提醒；4）与2wT工作人员就转诊和预约重新安排进行互动式短信交流。使用针对参与者人口统计学特征进行调整的混合效应逻辑回归模型，我们研究了核心2wT组成部分保真度对以下方面的影响：a）按时就诊，b）错过预约后及时复诊，并给出调整后的优势比（aORs）和95%置信区间（CIs）。
468名2wT参与者的研究周数中位数为52周（四分位间距[IQR] 34 - 52），有6次ART预约（IQR 4 - 7），其中2次（IQR 1 - 3）被错过。平均而言，参与者在登记周数的75%（IQR 56% - 83%）收到了激励信息，在83%（IQR 67% - 100%）的预约前收到了提醒，在67%（IQR 0% - 100%）的错过预约后收到了提醒。参与者通过2wT提示报告了9次转诊并重新安排了46次预约；196次预约通过非提示性互动进行了更改。预期激励信息发送率高10%的参与者更有可能按时就诊（aOR：1.08；95%CI：1.01 - 1.16，p = 0.03）。以任何方式接收并回复预约提醒也与按时就诊增加相关（分别为aOR：1.35；95%CI：1.03 - 1.79，p = 0.03和aOR：1.47，95%CI：1.16 - 1.87，p = 0.001）。未发现2wT信息与错过预约后及时复诊之间存在关联。
更高的2wT实施保真度与改善护理结果相关。虽然mHealth干预措施的实施保真度监测很复杂，但应将其纳入研究设计中。
