Participants’ perception on the feasibility of introducing a mobile health application into the HIV care and treatment program

Health system-related factors

The participants expressed belief that the health system has the necessary resources to support the use of the app. A health staff stated during a focus group discussion: “For now, all the workers here are using personal phones and the health system provides credit. The health system has not provided us with phones, but it’s possible they can provide phones just for the process” (FGD, Health worker Buea).

Adolescents and young adults also believe the health system has the capacity to fund the use of the mobile application in the HIV program to improve adherence. One participant stated: “If it is possible for them to give us free drugs, then it is possible they can provide accessories and cover the costs to run the app” (FGD, young adults Muyuka, M20). An adolescent supported this narrative by saying: “I think they can provide phones, and even data is not more than the program to provide to the staff” (FGD, adolescents Limbe).

Regarding whether the target population can accommodate the innovation, a health staff pointed out: “If you look at the number of hours youths spend on Facebook, TikTok, WhatsApp, etc., it is really high, and this doesn’t help them in their health. So, they can put those resources and time into an app that will help them promote their health?” (FGD, Health Staff Muyuka).

Acceptability of the mobile application in HIV care and treatment

Information about the acceptability of Mobile health was also gathered through focus group discussions, conducted among adolescents, young adults, and healthcare providers. The participants expressed varied opinions regarding the acceptance of the mobile application and whether they believed it would be embraced or not. Codes that emerged from the sessions indicated that a significant portion of the population would accept and use the application.

To support the notion of acceptance, some healthcare workers shared their perspectives. One health worker stated, “Adolescents will buy the idea because they first of all have android phones” (FGD, Health Staff Limbe). Another health staff member added, “It will even help to reduce stigma. The app will be greatly welcomed even by the clients because some of them try much to avoid stigmatization. You can interact with them more through the app, and they don’t need to always come here. They don’t need to come and meet someone they may know in the quarter” (FGD, Health Staff Buea).

Another participant mentioned having observed a similar mobile application working in the HIV program in another country and strongly believed that the application would be well-received in Cameroon. She said, “I think it will be a good thing. I have seen it in South Africa, and such an app really helps increase adherence. There, people even have cards that they slot at certain points, and they collect their drugs without necessarily going to the hospital. It is rare to see people going to the hospital except the condition is worst” (FGD, Tiko Health Staff).

Adolescents and young adults also expressed their belief that a mobile application idea would be welcomed and accepted. During the focus group discussions, an adolescent stated, “To me, I know the population will accept it” (FGD, Adolescents, Tiko). Furthermore, a young adult added, “The population will accept it. The app will be good because it is for some specific people and not the general public to an extent...” (FGD, Young Adults Buea).

Features of the Application from participants prospective

During the focus group sessions conducted at two level (health workers and clients), they shared their interest on important features they expect to see in such a mobile application. Participants expect the application to have the following features: reminder messages, appointment booking, a social corner, and the ability to share tips about HIV.

Majority of participants expressed a strong desire to receive reminder messages. An adolescent girl said, “Sometimes one sleeps and forgets the time to take treatment. With the app, we propose a loud reminder. For me, the reminder should be a sound” (FGD, Adolescent Tiko). Forgetfulness appears to be a significant challenge with adherence to treatment. A young adult in the focus group explained her need for reminders by saying, “The app should be able to remind us. Sometimes one gets busy and forgets to take the medication” (FGD, Young Adult Buea). A health worker also voiced her support for the reminder feature. She said, “Reminders would be helpful, especially for patients with high viral load. I think it will be of great advantage. If it is coming from the app, it has to be in coded language understandable to the patients” (FGD, Limbe).

Furthermore, participants also requested a feature that would allow them to book appointment visits. One health staff member explained, “Concerning appointments, it will ease communication between us and the clients. Some clients may not pick up calls or inform us that they will not be able to come. So, if the app has that feature, it will be good” (FGD, Health Staff Limbe).

Another participant made a suggestion regarding appointment booking, expressing a desire for appointments to be available for longer than 3days. She said, “The appointment feature is good, but let it be booked for around two weeks” (FGD, Young Adult Buea). The participants also a social corner will be a good to be included in the application. “It will be good to have a social corner in the app and let doctors be there too. The social corner can even help people find partners. At least the only worry will be following up on viral load suppression, not worrying about status anymore” (FGD, Young Adult Buea).

More participants welcomed the idea of a social corner within the app. A female staff member in Limbe stated, “It will still be good to have a social corner. Clients will be able to interact with one another, but anonymously” (FGD, Health Staff Limbe).

Participants believed that the application would not only help overcome stigmatization but also serve as a platform for encouragement for those who feel discouraged. A male young adult said, “A social community can be very helpful. People often stop treatment due to drug side effects. Some people can share their experiences and receive help and counseling through the social corner. They can explain their experiences and encourage others to stick to treatment. But everyone should be treated as anonymous in the app” (FGD, Young Adult Muyuka).

In addition to the desired features, health workers also emphasized the need for the app to provide health tips. One health worker expressed, “I think it will be a good app, if health tips will be provided to prevent treatment defaults, transitioning from first to second line, receiving reminders, etc. This will greatly enhance adherence” (FGD, Health worker Muyuka).

Some concerns participants had about such an Application

While the participants believe that the application will be helpful, many of them expressed concerns regarding the confidentiality of their information. Some concerns about confidentiality were raised by health providers and clients. One young adult stated, “To my view, you know many people will always like be confidential with their status. I think educating the population about the confidentiality of the app will encourage people to use the app” (FGD, Young Adults Buea). Another health worker asked, “My question is, how confidential is the app? Are you sure hackers would not hack the app like they do on Facebook and similar platforms?” (FGD, Health Staff / Data Clerk Tiko).

Another health workers, who also worked as a psychosocial worker, expressed concerns about confidentiality in relation to their coded discussions with clients. They said, “There are some clients who are not part of the support group here. I’m talking about adults or adolescents. We discuss drugs discreetly. We have coded discussions. If the conversations and notifications in the app can be coded as well, then it will be good. If not, confidentiality will be a problem” (FGD, Buea Health worker / Psychosocial Worker).

One health worker raised concerns about the lack of privacy in general, stating, “Today, you cannot claim that your phone is yours alone because someone can take your phone to verify something and end up checking other things. There is no confidentiality because you will start answering questions like ‘why and why?” (FGD, Health worker Limbe).

A young adult shared worry about someone they know finding them with the app and potentially revealing their status to their family. He said, “For me, I am a student and my father doesn’t know about my status. If someone outside of this age group who I know finds me with the app, they may tell my family, which is something I don’t want to happen. If that person cannot keep secrets, they will expose everything. You will suffer because the society doesn’t take it lightly on people with HIV. Everyone will ignore you and you will be left alone” (FGD, Young Adults Muyuka).

Another young adult emphasized the importance of privacy in social corner and the need to ensure that third parties cannot use the application or access shared data. They said, “The privacy should also involve social corner. Third parties should not be able to use the application, and sharing of data should be completely wiped out” (FGD, Buea Young Adult).

One participant suggested abbreviating the app name to avoid raising suspicion. They said, “Just imagine a friend picks up your phone and sees the app, it is kind of alarming. Maybe they can abbreviate or code everything” (FGD, Young Adults Limbe).

In addition, another health worker raised the issue on financial constraints, stating, “Let me speak for the children here. Most of them cannot even afford transportation or three-square meals to take their medication, let alone a phone and internet costs. Many of them are orphans because their parents have died” (FGD, Limbe worker Staff / Child Focal Point).

Discussion

In this study, we examined the feasibility and acceptability of mHealth in the HIV program, with a focus on adolescents, young adults, and their healthcare providers. We also aimed to provide information for evidence-based mHealth application development. A significant percentage of participants (66.4%) reported owning mobile phones, while 85.7% of the participants demonstrated proficiency in reading and writing in two-way text messages. This goes a long way to highlight the potential for mobile-based interventions within target population. A significant number of participants (93.3%) were proficient in using social media platforms, as observed through their responsiveness to WhatsApp messages. These findings are similar with reports from previous studies in developed countries, which show high rates of technology and mobile device use [13]. The participants also noted that the health system currently provides credit for program staff and has the capacity to fund the use of a mobile application to enhance program outcomes. These insights highlight the potential for integrating mobile technology into the health system in a sustainable manner. The use of mobile health applications in HIV has been studied in many other countries, both in young and adult populations with some benefits reported [6,14-18].

Significant proportion of participants (86.6%) expressed a strong interest in utilizing a mobile health application to enhance their care and treatment services. Health workers also noted that young people are likely to embrace the idea due to their familiarity with social media tools. This underscores the potential benefits and positive reception of incorporating a mobile application into the HIV program. In other studies, HIV clients used their phones at one point to facilitate their care and treatment [13,19]. Health workers also believe the innovation will be accepted, as it would help reduce stigma and allow for increased interaction with clients without the need for face-to-face meetings. Studies have shown that mHealth can address some barriers that impeded health care delivery in the young population [20-23].

Regarding the features of interest for a possible mobile health application, participants expressed the desire for an application that can provide reminders, prevention tips, drug side effects information, appointments, and a social corner. This finding is in agreement with previous studies that have shown how these functions can empower individuals to take an active role in managing their health, improve medication adherence, enhance preventive measures, and foster social support within a digital health community [7,13,24-27].

Participants also believe that the mobile health application will be helpful, however many of them expressed concerns regarding the confidentiality. Confidentiality concerns among adolescents and young adults living with HIV can be attributed to the fears of stigmatization and perceived discrimination. This is evident in the opinions of some participants who believe that if someone outside their treatment group learns of their HIV status, they will face significant negative consequences due to societal attitudes towards people living with HIV. Healthcare workers also share similar concerns about confidentiality, as they worry that mHealth application could be susceptible to hacking, citing their daily experiences with security breaches on social media platforms. These participant opinions align with cyber insecurity statistics, such as the reported hijacking of 25% of Facebook accounts and approximately 85% of Instagram accounts being hacked in 2023. The rapid shift to digital platforms during the COVID-19 pandemic also resulted in increased in hacking incidents [28].

The fear of confidentiality breaches among adolescents and young adults living with HIV is heightened by the fact that their healthcare providers hold discussions about their medications discreetly and use coded language. This is due to the concern that unauthorized disclosure of their HIV status could result in a breach of trust and potential harm to their reputation or relationships [29]. Other studies on the acceptability of mobile health application in the HIV program have also reported concerns from participants regarding the confidentiality of their information [5,13,16,29,30].

Conclusion

The findings of this study provide valuable insights into the potential of mHealth applications in the HIV program for adolescents and young adults. The study reveals evidence of high mobile phone ownership and proficiency in using mobile applications among the target population. However, it also emphasizes the need to prioritize and implement a robust system to ensure privacy and confidentiality during the development of a mobile health application. This is essential to guarantee the protection of sensitive health information and build trust among users.

Declarations

Ethics approval and consent to participate

The study was implemented in compliance with the Declaration of Helsinki on human subjects. Ethical clearance was obtained from the University of Buea Faculty of Health Sciences Institutional Review Board, with reference number 2023/187-01/UB/SG/IRB/ FHS.

Written informed consent was obtained from adult participants, and written assent was obtained from the guardians/parents of minors, ensuring their understanding and voluntary participation in the study.

Administrative authorization was obtained from the South West Regional Delegation of Public Health and the District Health Services of the respective districts involved in the study. Hospital Directors provided authorization to access the treatment centers in their various facilities.

Consent for publication: Not applicable

Availability of Data and Materials

The authors confirm that the data supporting the findings of the study are available within the article. However, the datasets used for the analysis are available from the corresponding author upon request.

Competing Interests

The authors declare that they have no financial or personal relationships that might have inappropriately influenced them in writing this article.

Funding

This study was conducted without any external funding. All resources utilized for the study were self-funded by the first author and the corresponding author.

Authors’ Contributions

CN conceived, designed and led the study implementation and data analysis, TN participated in the conception, designing and supervised the study implementation, PTNM participated in the designing and in developing the manuscript, EAT participated in the designing and field implementation, ETA participated in the field implementation, LKA participated in the field implementation and data analysis, TOE participated in the designing and supervised the study implementation PAN conceived, designed and supervised the study implementation. All authors read and approved the final manuscript.

Acknowledgements

We express gratitude to the South West Regional Delegation of Public Health for facilitating the implementation of this study by providing administrative authorization. We salute the commitment of the various focal persons in the centers that were involved in the study. We also appreciate all participants for their collaboration in the implementation of the study.

Disclaimer

All authors were involved in the study implementation.

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