Improving Knowledge About Pregnancy for Deaf South African Women of Reproductive Age Through a Text Messaging-Based Information Campaign: Mixed Methods Study.

BACKGROUND: Signing Deaf South Africans have limited access to health information and, consequently, limited knowledge about health. Maternal and neonatal mortality rates are high. Cell phone use is high, making it a potentially effective way of communicating about maternal and child health. OBJECTIVE: The primary aim of this study was to assess whether an SMS text messaging-based health information campaign could improve knowledge about pregnancy, antenatal care, and healthy living during pregnancy for signing Deaf South African women of reproductive age. The secondary aim was to evaluate the acceptability of such an intervention. METHODS: This study was designed as a pretest-posttest study. A baseline questionnaire assessed participants' knowledge about pregnancy, antenatal care, and healthy living during pregnancy before an SMS text messaging-based information campaign was conducted. After the campaign, an exit questionnaire was administered containing the same questions as the baseline questionnaire with additional questions on general acceptability and communication preferences. The results were compared between baseline and exit using the McNemar and Wilcoxon signed rank tests. A focus group aimed to obtain further information on the impact and acceptability of SMS text messages. The focus group was analyzed inductively. RESULTS: The study showed a statistically significant improvement in overall health knowledge among participants. Despite this, some participants found the medical terminology challenging to understand. Several ways of improving SMS text messaging campaigns for the Deaf were identified, including using Multimedia Messaging Services with a person signing messages and linking information campaigns to a communication service that would enable Deaf people to pose questions. The focus group also suggested that SMS text messages might play a role in motivating healthy behaviors during pregnancy. CONCLUSIONS: The SMS text messaging campaign effectively improved Deaf women's knowledge about pregnancy, antenatal care, and healthy living during pregnancy and has the potential to affect health behavior. This contrasts with a similar study on hearing pregnant women. This suggests that SMS text messages may be particularly effective in improving Deaf people's health knowledge. However, attention should be paid to Deaf participants' specific needs and communication preferences to optimize impact. The potential of using SMS text messaging campaigns to affect behavior should be studied. TRIAL REGISTRATION: Pan-African Clinical Trials Registry (PACTR) PACTR201512001352180; https://tinyurl.com/3rxvsrbe.

Validity and reliability of maternal recall of pregnancy history and service use among signing Deaf women: a cross-sectional descriptive study from South Africa.

INTRODUCTION: There is little credible quantitative data on pregnancy histories and outcomes for disabled women in low-income and middle-income countries. The purpose of this study, based in Cape Town, South Africa, was to test the reliability and validity of maternal recall of pregnancy history and service use among a sample of Deaf women who use South African Sign Language (SASL). METHODS: We interviewed 42 signing Deaf women of childbearing age (18-49 years) in SASL using a structured questionnaire in July 2016. To assess reliability, seven participants (16% of the sample) were reinterviewed by different interviewers under the same conditions after 10-30 min. For the analysis we used (1) Cohen's kappa, an inter-rater statistical method, and (2) overall percentage agreement. Validity was explored by comparing the participants' pregnancy history to the Western Cape Provincial Health Data Centre (PHDC) database. RESULTS: The reliability results showed that out of 19 questions 14 demonstrated substantial to perfect agreement kappa scores (kappa between 0.61 and 1) and 5 had the lowest kappa agreement scores (kappa <0.61). With respect to percentage agreement, participants provided identical responses in 87% cases. Overall, women provided more reliable responses to pregnancy outcomes compared with demographic information. Validity results showed that 29 out of 35 Deaf women provided survey responses that matched or nearly matched (83% agreement) the PHDC database for birth history and delivery location. CONCLUSION: This study suggests that for this sample of signing Deaf women recall of pregnancy history and service use is reliable and valid. Extending this approach to other similar populations will require further research, but it is important that methods to access hard-to-reach disabled populations are developed so that health system responsiveness to marginal populations can be based on robust evidence.

Access to palliative care in HIV services in Cape Town.

This paper examines access to palliative care (PC) for patients with HIV, part of a study investigating access to PC for patients with chronic diseases. Studies highlight gaps in symptom management and psychosocial care for People living with HIV (PLHIV) and thus the need to integrate PC into HIV services. The aim of the study was to describe the access of patients with advanced chronic illness to PC services. METHODOLOGY: this was a prospective cohort study conducted over six months. Participants were recruited from patients living with HIV with CD4 counts of <200 cells/mm3, patients with advanced cancer and patients diagnosed with motor neurone disease. All HIV patients were on anti-retroviral treatment. Participants responded to a questionnaire including the APCA African Palliative Outcome Scale (POS), a validated palliative outcome scale, as a measure of care at first visit and telephonically once a month for 6 months. RESULTS: Seventy-nine HIV patients were recruited to the study. During the study 6 PLHIV died and no HIV patients were referred to PC services. A significant finding is that most patient outcomes improved for HIV patients. Pain reduced from 1.83 to 0.86; symptoms reduced from 2.41 to 0.49; worry reduced from 2.17 to 0.35. Spiritual well-being also improved - life worthwhile from 3.56 to 4.74 and at peace from 3.63 to 4.86; all measures out of 5. A small sub-set of this cohort (7.7%) experienced high pain levels not controlled during the study. DISCUSSION: Few patients were referred to PC services despite 6 HIV deaths during the study. Patients attending HIV clinics received good PC in conjunction with HAART, suggesting that PC appears to be well integrated into routine HIV care. It is suggested that patients with severe problems including those who died would have benefitted from referral to PC.

The cost and utilisation patterns of a pilot sign language interpreter service for primary health care services in South Africa.

BACKGROUND: The World Health Organisation estimates disabling hearing loss to be around 5.3%, while a study of hearing impairment and auditory pathology in Limpopo, South Africa found a prevalence of nearly 9%. Although Sign Language Interpreters (SLIs) improve the communication challenges in health care, they are unaffordable for many signing Deaf people and people with disabling hearing loss. On the other hand, there are no legal provisions in place to ensure the provision of SLIs in the health sector in most countries including South Africa. To advocate for funding of such initiatives, reliable cost estimates are essential and such data is scarce. To bridge this gap, this study estimated the costs of providing such a service within a South African District health service based on estimates obtained from a pilot-project that initiated the first South African Sign Language Interpreter (SASLI) service in health-care. METHODS: The ingredients method was used to calculate the unit cost per SASLI-assisted visit from a provider perspective. The unit costs per SASLI-assisted visit were then used in estimating the costs of scaling up this service to the District Health Services. The average annual SASLI utilisation rate per person was calculated on Stata v.12 using the projects' registry from 2008-2013. Sensitivity analyses were carried out to determine the effect of changing the discount rate and personnel costs. RESULTS: Average Sign Language Interpreter services' utilisation rates increased from 1.66 to 3.58 per person per year, with a median of 2 visits, from 2008-2013. The cost per visit was US$189.38 in 2013 whilst the estimated costs of scaling up this service ranged from US$14.2million to US$76.5million in the Cape Metropole District. These cost estimates represented 2.3%-12.2% of the budget for the Western Cape District Health Services for 2013. CONCLUSIONS: In the presence of Sign Language Interpreters, Deaf Sign language users utilise health care service to a similar extent as the hearing population. However, this service requires significant capital investment by government to enable access to healthcare for the Deaf.

Health promotion via SMS improves hypertension knowledge for deaf South Africans.

BACKGROUND: Signing Deaf South Africans have limited access to health information. As a result, their knowledge about health is limited. Cell phone usage in South Africa is high. This study aimed to assess whether a short message service (SMS)-based health promotion campaign could improve Deaf people's knowledge of hypertension and healthy living. Additionally, the study aimed to assess the acceptability of using SMSs for health promotion targeting Deaf people. METHODS: A baseline questionnaire assessed participants' knowledge about hypertension before an SMS-based information campaign was conducted. After the campaign, an exit questionnaire was conducted, containing the same questions as the baseline questionnaire with additional questions about general acceptability and communication preferences. Results were compared between baseline and exit, using McNemar's test, paired t-test and Wilcoxon signed-rank test. Focus groups aimed to get further information on the impact and acceptability of SMSs. The focus groups were analysed using inductive thematic analysis. RESULTS: The campaign recruited 82 participants for the baseline survey, but due to significant loss-to-follow-up and exclusions only 41 participants were included in the analysis of the survey. The majority (60%) were men. Eighty percent were employed, while 98% had not finished high school. The campaign showed a statistically significant improvement in overall knowledge about hypertension and healthy living amongst participants. Six individual questions out of 19 also showed a statistically significant improvement. Despite this, participants in focus groups found the medical terminology difficult to understand. Several ways of improving SMS campaigns for the Deaf were identified. These included using using pictures, using 'signed' SMSs, combining SMSs with signed drama and linking SMS-campaigns to an interactive communication service that would enable the Deaf to pose questions for clarification. Focus groups suggested that participants who were hypertensive during the campaign adopted a healthier lifestyle. CONCLUSION: SMSs were effective in improving Deaf people's knowledge of hypertension and healthy living. However, SMS-campaigns should be cognizant of Deaf people's unique needs and communication preference and explore how to accommodate these. TRIAL REGISTRATION: The research was registered with the Pan African Clinical Trial Registry on December 1, 2015. Identification number: PACTR201512001353476 .

"They must understand we are people": Pregnancy and maternity service use among signing Deaf women in Cape Town.

BACKGROUND: Women with disabilities are at disproportionate risk for adverse pregnancy outcomes, however, there is limited information on their pregnancy histories. This mixed-methods study focuses on signing Deaf women whose access to health care may be compromised by language barriers related to their disability. OBJECTIVE: To describe and compare the pregnancy outcomes and maternity service use of a sample of signing Deaf women of child-bearing age in Cape Town to the population of the Western Cape of South Africa. METHODS: We interviewed 42 Deaf women selected by non-probability snowball sampling, using a structured questionnaire in South African Sign Language in Cape Town in July 2016. RESULTS: Average parity of the sample was similar to that of the Western Cape population. Most women had one or two children (74%). Thirty-one percent of women had experienced a miscarriage and 19% had terminated a pregnancy. Almost all women (96%) attended at least one antenatal appointment during their pregnancies, and all deliveries occurred at a health facility. Women primarily relied on writing to communicate during antenatal visits and labor/delivery. The majority of women reported communication issues due to limited interpretation services, and some reported experiencing mistreatment from hospital staff. CONCLUSION: This study provides novel information on the pregnancy histories of Deaf women. While maternal service usage was high, the quality of services were inadequate with reports of linguistic barriers and mistreatment. Findings suggest the need to improve maternity care for Deaf women through implementing interpretation services and providing sensitivity training to health care providers.

Hypertension Health Promotion via Text Messaging at a Community Health Center in South Africa: A Mixed Methods Study.

BACKGROUND: The use of mobile phones to deliver health care (mHealth) is increasing in popularity due to the high prevalence of mobile phone penetration. This is seen in developing countries, where mHealth may be particularly useful in overcoming traditional access barriers. Non-communicable diseases may be particularly amenable to mHealth interventions, and hypertension is one with an escalating burden in the developing world. OBJECTIVE: The objective of this study was to test whether the dissemination of health information via a short message service (SMS) led to improvements in health knowledge and self-reported health-related behaviors. METHODS: A mixed methods study was carried out among a cohort of 223 hypertension clinic patients, in a resource-poor setting in Cape Town, South Africa, in 2012. Hypertensive outpatients were recruited at the clinic and administered a baseline questionnaire to establish existing knowledge of hypertension. Participants were then randomly assigned to intervention or control groups. The intervention group received 90 SMSes over a period of 17 weeks. Thereafter, the baseline questionnaire was readministered to both groups to gauge if any improvements in health knowledge had occurred. Those who received SMSes were asked additional questions about health-related behavior changes. A focus group was then conducted to obtain in-depth feedback about participants' experience with, and response to, the SMS campaign. RESULTS: No statistically significant changes in overall health knowledge were observed between the control and intervention groups. The intervention group had positive increases in self-reported behavior changes. These were reaffirmed by the focus groups, which also revealed a strong preference for the SMS campaign and the belief that the SMSes acted as a reminder to change, as opposed to providing new information. CONCLUSIONS: Although the content of the SMSes was not new, and did not improve health knowledge, SMSes were effective in motivating positive self-reported behavior change among hypertensive patients. TRIAL REGISTRATION: Pan African Clinical Trials Registry Number: PACTR201412000968462. Registered 18 December 2014 (Archived by WebCite at http://www.webcitation.org/6fhtyLRcO).

Comparison of two text message (mHealth) campaigns for the Deaf: Contracted out v. conducted in-house.

Cell phone-based health information (mobile health or mHealth) campaigns are an emerging technology. This evaluation focused on the aspect of cost of two health information campaigns, one on hypertension and one on pregnancy. Researchers could either contract out the technical components of the campaigns or attempt to run the campaigns themselves, in-house. The in-house campaigns cost an estimated ZAR13 548.72 v. the private provider quotes which ranged from ZAR27 542.97 to ZAR34 227.59. Running the campaigns in-house was more labour intensive and required more technical expertise, but had a reduced delivery failure rate (9.2% in-house v. 30.0% private provider). Running small to medium SMS (text message) campaigns for evaluative purposes proved advantageous over contracting out to private providers. Larger-scale evaluations and full-scale roll-out will require the services of private providers, but it is still essential that researchers actively engage with and monitor the technical aspects of these campaigns.

Antenatal health promotion via short message service at a Midwife Obstetrics Unit in South Africa: a mixed methods study.

BACKGROUND: Adequate antenatal care is important to both the health of a pregnant woman and her unborn baby. Given South Africa's high rate of cellphone penetration, mobile health interventions have been touted as a potentially powerful means to disseminate health information. This study aimed to increase antenatal health knowledge and awareness by disseminating text messages about clinic procedures at antenatal visits, and how to be healthy during pregnancy. METHODS: Participants recruited were pregnant women attending a primary health care facility in Cape Town. A controlled clinical trial was carried out where the intervention group (n = 102) received text messages staggered according to the week of pregnancy at the time of recruitment. The control group (n = 104) received no text messages. These text messages contained antenatal health information, and were delivered in English, Xhosa or Afrikaans, according to the preference of each participant. A baseline knowledge questionnaire with nine questions was administered prior to the intervention. The same questionnaire was used with added health-related behaviour questions for the intervention group at exit. A modified intention-to-treat analysis was done. To compare the control and intervention group's knowledge, Fisher's exact tests and two-sample t-tests tests were carried out for binary and continuous outcomes, respectively. A focus group of seven participants from the intervention group was then conducted to gain more insight into how the text messages were perceived. RESULTS: There was substantial loss to follow-up during the study with only 57% of the participants retained at exit. No statistically significant difference was detected between the control and intervention group in any of the nine knowledge questions at exit (all p > 0.05). Responses from the focus group indicated that the text messages acted as a welcome reminder and a source of positive motivation, and were perceived as extended care from the health care provider. CONCLUSIONS: While the intervention failed to improve antenatal health knowledge, evidence from self-reported behaviour and the focus group suggests that text messages have the potential to motivate change in health-seeking behaviour. One should be mindful of loss to follow-up when rolling out mobile health interventions in developing country settings. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201406000841188. Registered 3 June 2014.