Assessing the Organizational Readiness in Using Unstructured Supplementary Service Data (USSD) to Improve Treatment Outcomes for Adolescents Living with HIV Transitioning to Adult Care at Umodzi Family ART Clinic

Assessing the Organizational Readiness in Using Unstructured Supplementary Service Data (USSD) to Improve Treatment Outcomes for Adolescents Living with HIV Transitioning to Adult Care at Umodzi Family ART Clinic | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing the Organizational Readiness in Using Unstructured Supplementary Service Data (USSD) to Improve Treatment Outcomes for Adolescents Living with HIV Transitioning to Adult Care at Umodzi Family ART Clinic Wapulumuka Joseph Masambuka, Alinane Linda Nyondo-Mipando This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6669133/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Introduction Adolescents living with HIV (ALHIV) face challenges transitioning to adult care. Mobile health interventions, particularly Unstructured Supplementary Service Data (USSD), have effectively improved HIV knowledge and treatment outcomes. While mobile penetration in Malawi has increased, there are no USSD interventions specifically for ALHIV. A proposed USSD application aimed to enhance treatment outcomes for this group. This study evaluated the organizational readiness of the Umodzi Family ART Clinic to implement this platform. Methods This qualitative exploratory study was conducted between November 2023 and March 2024 at the Umodzi Family Clinic in Blantyre, Malawi, focusing on healthcare workers and ALHIV transitioning to adult care. We conducted nine in-depth interviews with healthcare professionals and facilitated three focus group discussions with thirty-two ALHIV participants. All interviews and focus group sessions were recorded, transcribed verbatim, and analysed using NVivo 14 software, guided by the theory of organizational readiness to identify key themes. Results Our findings indicate a strong willingness among both ALHIV and healthcare workers to use the application to improve treatment outcomes during the transition to adult care. Key features like access to treatment information and reminders were recognized as vital for enhancing adherence, retention, and viral suppression. The presence of digital platforms at the facility, widespread mobile access among ALHIV, and the facility’s prior experience with digital health initiatives were major facilitators for the App's success. Nevertheless. enhancements in privacy, security, interoperability, and overall app design were highlighted as critical features for successful app adoption. Conclusion The findings demonstrate a significant readiness to embrace the proposed application to enhance treatment outcomes. Additionally, our results underscore essential pillars of organizational readiness that are vital in designing and implementing mHealth applications. The study's results are critical for developing and implementing USSD applications to support treatment outcomes for ALHIV transitioning to adult care. Adolescents Transitioning to Adult Care Mobile Health Unstructured Supplementary Service Data (USSD) Treatment Outcomes HIV/AIDS Organization Readiness Digital Health 1. Background The WHO reported that by 2019, over 1.7 million adolescents were living with HIV/AIDS, with 90% of the infection among those aged 15–24 years ( 1 ). Malawi, with an 8.9% HIV prevalence rate, has developed strategies in line with the 95-95-95 targets to join the global effort to end AIDS by 2030 ( 2 ). According to the recent Malawi Population-based HIV Impact Assessment (MPHIA) survey, the country is on track to reach epidemic control ( 3 ). However, to sustain these gains, strengthening linkages to care and retention on antiretroviral Treatment (ART), particularly among younger adults, remains crucial ( 4 ). Globally, Adolescents living with HIV (ALHIV) face significant challenges in accessing treatment and care, including poor retention, treatment adherence, low viral suppression, and loss of follow-up ( 5 ). Few interventions exist to support ALHIV, with support groups being the primary intervention that has shown evidence to improve retention and adherence to treatment ( 5 ). To support ALHIV, the Malawi Ministry of Health uses the Teen Club model. The model offers ART treatment and psychosocial support and has contributed to improved adherence, retention, and viral load suppression ( 6 , 7 ). The model is limited to ALHIV aged 10–19 years, leaving adolescents transitioning to adult care without support. Evidence has shown that ALHIV patients transitioning to adult care face significant challenges, including a high loss to follow-up, poor adherence, and virological failure, exacerbated by structural system issues like lack of guidelines, staff training, and infrastructure ( 8 – 10 ). There is, therefore, a need to develop and implement interventions to support treatment outcomes for ALHIV transitioning to adult care. One of the interventions gaining traction in supporting patient treatment outcomes is Mobile health (mHealth). Evidence shows that mHealth is crucial in improving HIV/AIDS knowledge, adherence, retention, and psychosocial support ( 11 – 13 ). Unstructured Supplementary Service Data (USSD) is a mobile communication protocol used in mHealth platforms, enabling real-time interaction through menu selections ( 14 ). USSD-based applications can be used offline on smartphones and regular phones and are provided free of charge to the user. Studies in adolescent health have shown that USSD-based applications offer an excellent platform for treatment support and improvement of health knowledge in low-resource settings ( 15 , 16 ). Malawi has seen rapid mobile phone and USSD application usage growth, with mobile connections accounting for 51.4% of the population as of January 2022 ( 17 ). Despite challenges, the nation has effectively adopted mHealth applications to enhance healthcare and treatment outcomes ( 18 ). Although the country's youth mobile phone usage is increasing, mHealth initiatives remain underutilized. mHealth solutions could improve treatment and health outcomes. Unfortunately, no known USSD-based interventions exist for ALHIV in the country. To understand the readiness in the usage of mHealth to support ALHIV transitioning to adult care. This study was conducted to assess the organizational readiness in using Unstructured Supplementary Service Data (USSD) to improve treatment outcomes For Adolescents Living with HIV transitioning to Adult Care at Umodzi Family ART Clinic. The results of the study have the potential to improve treatment outcomes for ALHIV transitioning to adult care. 1.1 Description of the Umodzi USSD for Adolescents App The proposed application is a novel initiative under development to support ALHIV transitioning to adult care at the Umodzi Family. The author is developing the App with support from a software developer with experience in USSD-supported Applications. The App will utilize provider-based promptings through Short Messaging System (SMS) messaging and user-based prompting through access to the unique USSD code provided at a facility linked to the client's mobile number. Through password-protected logging into the USSD platform, a menu with critical themes will appear to prompt engagement with the user. The key themes will be developed based on the teen club curriculum that aims to improve treatment outcomes. The menu will prompt the user to access information on the key themes, including: Adherence - Under this theme, key messaging on adherence will be accessed, and the user's next appointment dates will be displayed. Viral load (VL) monitoring – Key messages on VL monitoring, treatment failure, and routine VL monitoring milestones will be generated, and the next appointed dates for VL testing will be listed. Opportunistic infections—Key messages on common symptoms of opportunistic infections will be generated, along with typical symptoms and treatment options. Psychosocial Support—Key messages on psychosocial challenges will be generated, and the avenues for support will also be listed. Linkage and referrals – key links to support services will be listed. A toll-free number on each theme will be listed on the drop-down list to provide an option to speak to a health provider for further information and engagement. Engagements on the application will be stored on the facility's server. 1.2 Theoretical framework A theory of organizational readiness for change was used to assess the organizational readiness of the Umodzi family ART clinic to implement a USSD-based application to support treatment outcomes for ALHIV transitioning to adult care. The theory of organizational readiness looks at an organization’s members’ shared resolve to implement a change (change commitment) through a shared collective capability to do so (change efficacy) ( 19 ). The following domains were assessed to assess the organizational readiness to implement an intervention: contextual factors, which examined the organizational culture that encourages innovation, risk-taking, and learning, flexible policies, and positive experiences with past changes and interventions. We also assessed change valence, which looked at the staff members' perceived value in the planned change due to its urgency, effectiveness, and anticipated benefits in supporting ALHIV transitioning to adult care. Lastly, change efficacy was also assessed to appraise the task demands the application would add to existing work and resource availability, including mobile access for the ALHIV. The theory was crucial in understanding the facility's readiness to use the application because it incorporated the identified facilitators and barriers in the critical constructs for the intervention to succeed. 2. Methods 2.1 Study Design The novelty of the idea necessitated a qualitative exploratory study conducted from November 2023 to March 2024 to assess the organizational readiness for utilizing mHealth to enhance treatment outcomes for ALHIV transitioning to adult care, with healthcare staff and ALHIV transitioning to adult care. 2.2 Study Settings The study was conducted at the Umodzi Family ART Clinic, Queen Elizabeth Central Hospital in Blantyre, Malawi. The facility is one of the largest ART centers in the country and is part of the Lighthouse Trust Centres of Excellence. The facility provides HIV testing, treatment, and care services. Patient data management is managed through an electronic records management system and a toll-free line to facilitate further engagement between healthcare workers and patients on treatment. As of May 2024, the facility had a cumulative register of over 40,000 patients, and with 16,000 currently alive and on treatment, 7% of those on treatment are young people aged 15–24. Treatment and care are provided by the facility from Monday through Friday. Every Saturday, the Teen Club clinic offers care and support to adolescents living with HIV (ALHIV) aged 10 to 19. The clinic is overseen by health professionals, volunteers, and trained mentors. In addition to receiving medication, members of the Teen Club engage in a curriculum that covers various topics aimed at improving treatment outcomes and medication adherence. The club also provides peer support and psychosocial guidance for ALHIV. Each year, all HIV-positive individuals over the age of 19 are transitioned to adult care. Before transitioning, a readiness assessment is conducted, and those who qualify receive transition training to prepare for the adult clinic. Unfortunately, the loss of support from the teen clinic creates significant challenges for adolescents living with HIV (ALHIV) as they move into adult care. This transition often results in poor adherence to treatment, virological failure, and loss to follow-up, all of which are exacerbated by systemic issues such as inadequate infrastructure, insufficient staff training, and the lack of clear guidelines. 2. 3 Sample Size and Selection of Participants Participants were selected from the facility using a purposive sampling approach. We included participants aged 18 years and older, literate, and who had attended TC for more than three years, with access to a mobile phone. Gender, age, and phone ownership did not affect the selection to participate in the study. A database of recently transitioned ALHIV was used to identify potential participants. Phone calls were randomly made inviting ALHIV to participate in FGDs, while randomly selected health workers were approached and invited to participate in the In-depth Interviews. Thirty-two [32] participants participated in the study. Eight [8]) healthcare workers and support staff participated in the in-depth interviews, while twenty-four [24] ALHIVs participated in three [3] focus group discussions. 2.4 Data Collection The framework guided the development of data collection tools (Appendices 1 and 2) based on the theory of organizational readiness. Healthcare workers at the Mangochi District Health Office pretested these tools, with no modifications made, and the pretest results were excluded from the main study. Data collection took place between December 2023 and January 2024, conducted by the author and a professional data collector. In-depth interviews (IDIs) were held in both Chichewa and English, while focus group discussions (FGDs) were conducted solely in Chichewa, lasting approximately thirty to forty-five minutes and including participants of various ages and genders. All interviews occurred in a secure office at the facility, convenient for interviewees, and were digitally recorded with notes as backup. Observations in the clinic assessed contextual factors related to service delivery. There were no follow-up interviews, and participants were not granted access to transcripts. No refusals to participate were recorded. The transcripts were reviewed daily to check for data saturation and sample size adequacy. Saturation was achieved by the 8th interview and the second FGD, but an additional FGD was held to include more participants and maintain gender balance. To ensure data credibility, we validated key points with participants, including adolescents in transition, nurses, clinicians, mentors, and psychosocial counsellors. We aimed for transferability and confirmability by providing a detailed description of the study setting and methods, creating an audit trail for others to follow. 2.5 Data Management and Analysis All interviews were audio recorded and carefully transcribed, except for those conducted in Chichewa, which were translated into English. The transcripts were stored on a password-protected PC and imported into NVivo 14 for data management and analysis. A qualified research assistant conducted the transcription, and WM double-checked them. The study PI developed the codebook using the theory of organizational readiness for change constructs as a guide. All transcripts were analysed using deductive analysis to identify codes linked to specific framework constructs. Identical and recurring codes were then categorized into themes per the study's objectives. 2.6 Ethics The Umodzi Family ART Clinic management and the Queen Elizabeth Central Hospital research committee approved the institutional request, and the College of Medicine Research and Ethics Committee (COMREC P.09/23–0310) granted ethical approval. Written informed consent was obtained from all study participants before the interview and focus group discussions. Participation in the study was voluntary. 3. Results Nine medical professionals participated in the study, and twenty-four adolescents, with a median age of 19, attended the focus discussions. Every participant completed secondary education and had access to a mobile phone, with 87% having a personal phone. Table 1 Socio-demographic characteristics of study participants Type of Interview Sex Participants Phone Access Participants FDGs (n = 3) Female 10 ALHIV With Access 20 Male 14 ALHIV Without Access 4 Table 2 Socio-demographic Characteristics of Health Care Workers Type of Interview Sex Number of Participants IDI Female 3 Male 5 Total 32 Table 3 Constructs and Themes Construct Category Sub-Category Facilitators Barriers Change Valance Potential to improve treatment, provide vital information, and enhance retention, adherence, and viral suppression. No significant barrier was identified. Enhancing knowledge on treatment for ALHIV transitioning to adult care is crucial for the enhancement of treatment outcomes. Change Efficacy Task Demands No extra task demands on Clinical team Extra demands to burden the ICT Team Resource availability High mobile phone access for the ALHIV Restriction to access for platforms supports the application Essential Resources Available (i.e., hotline, servers, and personnel) Situational factors Need for engagement for ALHIV Post-Teen Club to improve outcomes. Reservations On Security Application to alleviate logistical challenges in accessing vital information Contextual factors Organizational culture Previous Positive Experience with mHealth Application. Negative experiences with the use of mHealth Application Experience with using other USSD Platforms Policies and Procedures Availability and awareness of mHealth-related policies and procedures Gaps in the availability and staff awareness of mHealth Related Policies App Desing Need for additional themes to the drop-down list. Usability Fears 3.1 Change Valance: Opportunity to optimize treatment The term "change valence" describes how prepared an organization is for change, with members embracing planned changes due to the urgency, efficacy, and potential benefits ( 19 ). The USSD application was deemed appealing to ALHIV and healthcare workers due to its potential to enhance treatment, provide essential information, and promote retention, adherence, and viral suppression. Both healthcare workers and ALHIV felt that the application would provide easy access to information on side effects, appointment dates, and next viral load milestone dates, which are vital to enhancing treatment outcomes. In addition, the participants felt that adopting the application would reduce structural barriers like waiting times and distance. ‘This platform is good, over time, because it will save time and improve treatment outcomes. You see most of the problems that we've got, especially when it comes to men and boys; they don't have that interest in coming to the facility most of the time because they are ok, and the time they are presented to the facility, they are presenting at an advanced stage, so with this kind of facility, they will even improve the prognosis of opportunistic infections and the treatment outcomes might also be quite well managed with this kind of platform’ – Clinical Officer 2. “It is useful because we may forget the date of appointment to visit the facility, you may easily check on the App and get the response, unlike not knowing the date you may think of just visiting the facility anyhow”- Adolescent 1 ‘This App will close that gap (information on enhancing their treatment outcomes). Since they are growing up, they will need to be searching and getting information. This App will make sure that they are getting the correct information. So, if they have something, they will say, let me go to the App and see what information it is. - Data Manager 3.2 Change Efficacy: Task demands, Resource Availability, and Situational factors. Changing efficacy is a key component of change implementation, based on how cognitively organizational members assess task demands, resource availability, and situational factors ( 19 ). To determine the change efficacy, we evaluated the task demands, resource availability, and situational factors to see if the facility was prepared to implement the intervention to enhance outcomes for ALHIVs transferring to adult care. 3.3 Staff Task Demands First, we sought to determine whether task demands would change because of the application's launch. The main emphasis of our assessment was whether the intervention would create bottlenecks or enhance regular tasks. The clinical participants who were interviewed all expressed that the intervention would not lead to additional task demands that would negatively impact the way operations are conducted at the facility. ‘If this adolescent did not have the information that he had gotten from the App, either they were supposed to call me, or they were supposed to come to the clinic. That will result in extra work, but they will not come to me if they have that information at home. At least, they will only come to me when there is probably somewhere where they don't understand. I will only explain where they did not understand, than narrating the whole story’ - Clinical Officer 1 It was additionally stated that the intervention would provide an additional level of assistance to assist ALHIV patients transitioning to adult care. Based on our observations, the clinic was rather busy and heavily overcrowded, making it difficult for nurses and doctors to engage participants for extended periods. Due to the congestion, the drug-collecting process took approximately two to three hours. These sentiments were backed by the healthcare workers working at the facility. ‘As previously stated, individuals may have inquiries but refrain from asking or receiving the desired response. As you can see today, a few clinical rooms are operational, which increases the waiting time. So for the person to ask more questions, they'll be like, hey, I'll be delaying people outside, so I can't ask the question. But if they have a platform where they can ask things or want to know about the viral load challenges, sometimes the patient will come, and then you fail to give them the result. And then they go home. I'm like, ah, they didn't give me my results. They can easily check’- Nurse 1 3.4 Resource availability Resources for the proposed change are another essential factor in determining the readiness for change. In addition to the intervention's need to function within the current platforms, resources supporting the change are crucial for the intervention to be successful. Adolescents' access to mobile phones was critical to the intervention's success. We assessed the adolescents' access to mobile phones and found that, of the 24, 20 had a personal phone, and the other 4 had unrestricted access to their guardians' phones. Furthermore, we explored the accessibility of hotlines, computer servers, and networks—all required for the intervention. The facility could support the application because it managed its local network and had an operational hotline, which are essential to its success. ‘We already have a hotline where clients can call using that line. For IT facilities, I think we've got a good one; the network is not an issue, and maintaining the application, I believe, has to do with the application developer working hand in hand with the IT guys, which we already have. - Clinical Officer 2 On the other hand, it was contended that for the application to be effective, it had to interface with current platforms and systems. The application's architecture should be interoperable with existing platforms to prevent duplication of work and system isolation. ‘It must work with the already-existing systems. This means that you must thoroughly assess the existing systems. And then you see how this one will blend in with what's already on the ground. How will the application blend into the already existing system? And the already existing resources. That's why I think I mentioned cost-effectiveness and efficiency as well. To lessen the burden, make it more; if you do, it should improve the system or application’. - Data Manager 3.5 Situational factors Situational factors also influence the efficacy of change. Examples of situational factors are the time required to accomplish a change and other aspects of the internal and external environments that facilitate a planned change. One of the most critical situational factors crucial for improving treatment outcomes for AIDS is the need for ongoing engagement with ALHIV as the transition to adult care. ALHIV and healthcare providers underscored the importance of continuing engagement to ease the transition and improve treatment outcomes. ‘They (ALHIV) develop a high viral load after graduating. This means that in adult care, something is lacking in this team, which was being managed when they were at the teen club. Then, the way we do it—leave them—has also shown that when they were adolescents, their viral load suppression or retention was good, but the moment they transition out, you can see that it's not good- Nurse 2 Since we are now in adult care, the interval between taking the drugs will be longer than before. We were receiving them at two monthly intervals; now, it is six months, so it is challenging to maintain drug adherence. They are supposed to call us at some point to remind us – Adolescent 4 Adjustments made to the intervals between clinic visits (three months to six months) due to transition made it apparent that to guarantee maximum adherence and viral suppression, a platform would be necessary to regularly remind adolescents about clinic appointments and viral load testing milestones, which are critical for good treatment outcomes. It was anticipated that the application would help adolescents get regular reminders about clinic appointments and viral load milestones. It (the application) is helpful because we may forget the date of the appointment to visit the facility, you may easily ask and get the response on the App, unlike not knowing the date, you may think of just visiting the facility anyhow. – Adolescent 5 “They can just go on the USSD app and access information. You also mentioned that there might be an update regarding their viral load so they can check, and if they've got a high viral load, there should be some of the information already there that should assist them in working around their issues with viral load and adherence before they come to the clinic - Clinical Officer 1 Nonetheless, adolescent concerns about security and privacy were identified as one of the main obstacles to the application's successful implementation. Unintentional disclosure can result in the stigmatization of those living with HIV, which is still one of the issues in the care of HIV patients. ‘The challenge is that some friends may come and check what you are doing on the phone, and you get to realize too late that he or she has read what I was doing.' – Adolescent 7 ‘So, let’s assume that you have opened the Application with your PIN, but you have forgotten and just left a phone somewhere; how long will the message be displayed?'. – Adolescent 12 3.6 Contextual factors The organization's readiness for change can be impacted by contextual factors, such as a culture that values creativity, risk-taking risks, learning, flexible regulations and processes, a healthy workplace culture, and a positive experience with change. These contextual factors were also assessed to determine the facility's readiness in implementing the application. 3.7 Organizational culture We were particularly interested in the facility's positive experiences with mobile health platforms. To do so, we assessed the facility's prior successes in utilizing mHealth platforms. The electronic patient management systems at the facility were found to be operational, and the toll-free hotline was found to be an effective tool for patient engagement. ‘One of the major successes of mobile technology for the facility is that we're able to retain clients through our hotline number. Clients travel but don't know where to go or how to get the medication, and then they will call us, and we guide them. We say they go to the closest facility, where they are assisted, and then we update their file to say they're still taking medication’ – Clinical Officer 2 ‘Just to give you an example, we've got a program for people staying in the diaspora. We've got a digital platform with an app whereby if someone goes outside Malawi when they get the medication, we scan them. We put them into that system in the event they go somewhere else, and then someone is trying to ask about their medication. What we do is check on the batch number, we go online, and then we verify this is coming from us, so we've got those kinds of already existing policies that are promoted in this kind of – Clinical Officer 2 Despite the successes registered, some applications have had challenges. One of the reasons for the failure of mHealth applications was the lack of interest among health workers. ‘Sometime back, we had an app that was assigned to the pharmacy; that app did not go well because there was no interest in the application.' – Nurse 3 3.8 Policies and Procedures Policies have a critical role in implementing change. Thus, policies and processes ought to support change. To facilitate the mHealth-related interventions, we explored whether the facility had the requisite policies and procedures. Among the policies considered crucial for the application's success included privacy, security, and patient data protection policies. The study, therefore, sought to determine whether the participants were aware of policies and procedures to support mHealth efforts. Unfortunately, all the staff interviewed were unaware of any mHealth-related policies and referred us to the data manager, based at the facility headquarters in another city. ‘ Well, on that one, I'm not so sure about that. I think the IT personnel should better answer that; they should have plans for that – Tracer 2 Furthermore, most respondents indicated that the facility's patient confidentiality policy was one of the most critical components of managing patient data and confidentiality. It was also reported that the institution had strong safety measures for patient-level data and digital health platforms, even without mHealth policies. ‘ Our systems are secured. Even the EMR we're talking about. The providers have their password, username, and password. It's all part of patient-level security and data security – Data Manager 3.9 Application Design A recurrent theme around the application's design was identified during the data analysis. This theme stood out because it did not fit with the initial themes developed for the study. Furthermore, we needed to highlight the importance of the design features and usability of the application, which are crucial for its success. Several areas around design stood out, and one of the areas that registered highly in the IDI was the need for additional themes on the menu. Sexual Reproductive Health (SRH), Pre-Exposure Prophylaxis (PrEP), and drug monitoring were some of the critical areas that were suggested by both the healthcare workers and ALHIV. On the part of other services, the linkage should be there; issues related to SRH are some information they lack. Even the referral is essential if possible; most adolescents are just about to get pregnant, which means that family planning concerns aren't well taken care of. They even fail to protect their lovers with PREP because they don't have that information. If it is possible, include it – Nurse 3 Another thing to add is a drug monitoring tool, where we can be able to know how many drugs are remaining and when I will be visiting the facility to meet the nurse. – Adolescent 8 Secondly, the functionality and usability of the application were a notable factor for the success of the intervention. ALHIV and healthcare workers stressed the need to ensure the system was user-friendly and efficient. I think another thing should be that you ensure that the system doesn't crash because it's a beautiful thing, but then if it's a thing that keeps on crashing, it won't save the purpose of reaching out to them. – Clinical Officer Adolescents also argued for needing healthcare workers with experience working with adolescents. Since most adolescents have previously worked with a group of trained mentors, it was argued that they need to continue with a similar group of professionals to manage the application and the hotline. We can't be open to everybody to say something, so when calling, if it is possible, choose one to talk with. Will that be possible? - Adolescent 11 The IDIs with the healthcare workers also reemphasized the need to have people with interest and experience in working with adolescents as part of the team to manage the application. Having a team of health workers with experience in working with ALHIV will ensure a better understanding of the needs of the ALHIV. We need to have people who are interested in this. If you approach the mentors, they are already interested in adolescents. Those people are the ones to be at the forefront. So, adolescents should not take time if they ask for something. Most of the time, when they are asking for something, they have a challenge that needs to be addressed promptly. So, there is a need to say that these people, on this end, must have an interest, need to have an interest, and two must know the adolescent behavior, status, and needs. – Nurse 3 4. Discussion The study's main findings demonstrate that adolescents and healthcare professionals were willing to use the application to improve treatment outcomes as they transitioned to adult care. Secondly, our findings also highlight the importance of the intervention in continuing engagement during the transition to adult care, which is critical for ALHIV. We also found that implementing the application would not have a detrimental effect on the tasks that healthcare workers were anticipated to perform. Furthermore, the facility's previous experience with mHealth applications and the availability of resources was seen as a significant facilitator to the success of the application. Mobile phone access was also highlighted as an essential facilitator of the application, with all adolescents who participated in the study having mobile phone access. However, interoperability and design concerns likely hindered the application's implementation and required addressing for the App to operate effectively. Both healthcare workers and ALHIV acknowledged that the application was essential in enhancing treatment outcomes in transitioning to adult care. Participants felt that the application would help provide appointment reminders and access to vital information that is key to improving treatment outcomes. This resonates with other studies showing healthcare workers' and patients' perceived appreciation of mHealth applications' role in reducing missed appointments, improving communication between healthcare providers and patients, and assisting in education and motivation. ( 21 ). A study in Zimbabwe revealed that healthcare workers considered a Viral Load SMS intervention essential for improving patient adherence and managing Viral health facilities ( 22 ). A USSD-based application study among adolescents in Kenya showed that USSD-based applications are critical to improved decision-making regarding sexual reproductive health ( 23 ). The results further demonstrate that the introduction of mHealth applications improves the clinical management of patients and enhances service delivery without adversely affecting task demands. Results from a qualitative evidence synthesis on Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare service revealed that mHealth applications improved the work flexibility, task-taking, and engagement of clients in challenging locations. ( 24 ). The synthesis further found that healthcare workers valued improved feedback and the speed of workflow that mHealth applications presented. The study further found that a toll-free hotline at the facility and the availability of already-existing ICT platforms were significant facilitators to the application's success. Studies have shown that a lack of infrastructure is one of the biggest obstacles to the adoption and long-term viability of mHealth applications in many low-resource settings. A systematic review on barriers to using mobile health in improving health outcomes in developing countries found that lack of infrastructure and equipment were among the top barriers to implementing mHealth Interventions. ( 25 ). The availability of the said resources at the facility presents a significant opportunity for the application's success. Additionally, we discovered that almost all the study's adolescent participants had access to mobile phones, which was a crucial cog in implementing the application. Furthermore, we also found high access to a mobile phone among adolescents in the study presented a significant building block for rolling out the application. The Sub-Saharan Africa (SSA) region has a considerable opportunity to improve health outcomes, especially HIV treatment adherence, as evidence suggests that the region's mobile phone penetration is increasing. Evidence further shows that adolescents are utilizing mHealth to support health outcomes. A systematic review of mobile health interventions for young people found they effectively improved contraceptive use, sexual health knowledge, and HIV treatment adherence ( 26 ). Another prerequisite for guaranteeing the App's success was its integration with already-existing applications. Participants underscored the need for integration with existing platforms to ensure success. Research demonstrates that most mHealth interventions fail due to challenges around integration and interoperability. Interoperability refers to the ability of information systems, devices, and applications to access, exchange, and integrate health data between multiple organizations, systems, or care settings. Evidence indicates that a lack of interoperability in new interventions is one of the significant barriers to providers because of the burden of their work processes and healthcare costs ( 27 ). For the application to succeed, it must integrate with existing platforms, including the facility's electronic patient management systems and networks, to ensure efficiency and effectiveness. Our results further suggest that continued engagement with ALHIV is necessary to improve a seamless transition from adolescent to adult care, which is crucial to achieving better treatment results. Health professionals and teenagers alike were enthusiastic about the application as they believed it would be helpful to the engagement of ALHIV transitioning to adult care. Transitioning to adult HIV care continues to be riddled with challenges, and there is a need for interventions that would enhance engagement between healthcare workers and adolescents. Both healthcare workers and ALHIV felt the application would provide appointment reminders and vital information for treatment outcomes. In other settings, evidence has shown that mHealth presents an excellent avenue to support treatment outcomes for people in HIV care and has the potential to improve outcomes and retention in YPLHIV ( 28 ). On the other hand, privacy was highlighted as one of the major fears in implementing the application. Adolescents were worried about unintentional disclosure to friends and asked for more robust security measures to safeguard their privacy. This aligns with the literature showing that most healthcare workers and patients share concerns about privacy and security. ( 29 , 30 ). One way to address the privacy and security gaps is through policies and frameworks to guide mHealth intervention. Unfortunately, apart from the patient confidentiality procedures at the facility, all participants interviewed were unaware of the policy framework guiding mHealth interventions at the facility. Other findings have shown that poor policy and regulations remain one of the biggest obstacles to the scalability and sustainability of mHealth in the country ( 31 ). To overcome this gap in policy implementation, mHealth developers must ensure that applications have security features and means to prevent unintentional disclosure. One way to address unintended disclosure includes using neutral messaging that refrains from discussing health-related or medication-related topics ( 32 ). Access control and authentication provide another alternative to ensure that privacy is maintained. Unfortunately, it is still difficult to verify if the intended recipient is using the application on the other end ( 33 ). Lastly, our findings show that it was vital to consider user demands in the application's design and usability. Aside from ensuring the application was user-friendly, participants felt it necessary to include additional topics in the drop-down menu, including SRH, PrEP, and drug monitoring. Evidence has demonstrated that challenges with usability and a lack of patient or user engagement in the design process contribute to the low uptake of mHealth interventions ( 34 ). User engagement is, therefore, pivotal in designing and implementing mHealth Applications. It is crucial to engage the ALHIV and health care workers in the design of the application to ensure its success in enhancing treatment outcomes for ALHIV transition to adult care. 4.1 Strengths and Limitations of the Study The study's main strength is that it involved the ALHIV and healthcare workers, the intended primary users of the application. However, it is also important to point out the study's limitations considering the findings. First, the study was conducted in an urban facility with already present platforms and systems that could promote mHealth, which may not be the same in other facilities. In addition, most of the ALHIV population interviewed were from urban settings, and mobile phone penetration may not be transferable to other rural settings. 5. Conclusion The study findings demonstrate a readiness in the facility to use and adopt the application to support treatment outcomes for the ALHIV transitioning to adult HIV care. Both ALHIV and healthcare workers are willing to use the application. The application was deemed essential in providing reminders and vital information key to the treatment and care of HIV. Facilitators for the successful application implementation include high mobile access among adolescents, availability of the ICT platforms and the toll-free line present, and the facility’s past success with other mHealth platforms. However, for this to be achieved, the privacy and security of the application must be enhanced. The application's effectiveness also depends on the engagement of health professionals and ALHIV in the development process. These findings add to the organization's readiness for mHealth interventions and offer significant insights on mHealth applications for ALHIV transitioning to adult care and enhancement of treatment outcomes. Declarations Ethics approval and consent to participate The Umodzi Family ART Clinic management and the Queen Elizabeth Central Hospital research committee approved the institutional request, and the College of Medicine Research and Ethics Committee (COMREC P.09/23-0310) granted ethical approval. Written informed consent was obtained from all study participants before the interview and focus group discussions. Participation in the study was voluntary. Consent for publication Not Applicable Availability of data and materials Data sharing is not applicable as no datasets were generated or analysed during the current study. Competing interests The authors declare that they have no competing interests Funding U.S. President’s Emergency Plan for AIDS Relief, U2GGH002173 Authors' contributions WM developed the protocol, conducted the data analysis and wrote the manuscript. ANM guided the protocol development, data analysis and the manuscript writing Acknowledgements We thank the staff and clients at the Umodzi family ART Clinic for their support during study and the Malawi HIV Implementation Research Scientist (MHIRST) Training Program the for support and mentorship References Young people and HIV. National Strategic Plan for HIV and AIDS 2020-25 Final. Malawi Population-based HIV Impact Assessment 2020-2021 Malawi Population-based HIV Impact Assessment MPHIA 2020-2021. Available from: http://phia.icap.columbia.edu Malawi Excels on UNAIDS 95-95-95 Treatment and Viral Suppression Targets - EGPAF [Internet]. [cited 2022 Jun 7]. Available from: https://pedaids.org/resource/malawi-excels-on-unaids-95-95-95-treatment-and-viral-suppression-targets/ Adolescent and young adult health [Internet]. [cited 2022 Mar 15]. Available from: https://www.who.int/news-room/fact-sheets/detail/adolescents-health-risks-and-solutions Mackenzie RK, van Lettow M, Gondwe C, Nyirongo J, Singano V, Banda V, et al. Greater retention in care among adolescents on antiretroviral treatment accessing "Teen Club," an adolescent-centered differentiated care model compared with standard of care: a nested case-control study at a tertiary referral hospital in Malawi. 2017; Available from: http://onlinelibrary.wiley.com/doi/10.1002/jia2.25028/full MALAWI: DISTRICT HEALTH SYSTEM STRENGTHENING AND QUALITY IMPROVEMENT FOR SERVICE DELIVERY. 2018. Dahourou DL, Gautier-Lafaye C, Teasdale CA, Renner L, Yotebieng M, Desmonde S, et al. The transition from pediatric to adult care of adolescents living with HIV in sub-Saharan Africa: Challenges, youth-friendly models, and outcomes. J Int AIDS Soc. 2017 May 16;20. Bailey H, Cruz MLS, Songtaweesin WN, Puthanakit T. Adolescents with HIV and transition to adult care in the Caribbean, Central America, and South America, Eastern Europe and Asia and Pacific regions. J Int AIDS Soc [Internet]. 2017 May 16 [cited 2022 Mar 17];20(Suppl 3). Available from: https://pubmed.ncbi.nlm.nih.gov/28530040/ Galagade J, Mwapasa V. An evaluation of the effectiveness, facilitators, and barriers of HIV Teen Clubs in achieving a successful transition from teen to adult care in Blantyre, Malawi, using the RE-AIM Framework. Available from: https://doi.org/10.21203/rs.3.rs-39459/v2 Chory A, Nyandiko W, Martin R, Aluoch J, Scanlon M, Ashimosi C, et al. HIV-Related Knowledge, Attitudes, Behaviors, and Experiences of Kenyan Adolescents Living with HIV Revealed in WhatsApp Group Chats. J Int Assoc Provid AIDS Care. 2021;20. Chory A, Callen G, Nyandiko W, Njoroge T, Ashimosi C, Aluoch J, et al. A Pilot Study of a Mobile Intervention to Support Mental Health and Adherence Among Adolescents Living with HIV in Western Kenya. AIDS Behav [Internet]. 2022 Jan 1 [cited 2022 Mar 17];26(1):232–42. Available from: https://pubmed.ncbi.nlm.nih.gov/34292429/ Mbuagbaw L, Van Der Kop ML, Lester RT, Thirumurthy H, Pop-Eleches C, Smieja M, et al. Mobile phone text messages for improving adherence to antiretroviral therapy (ART): a protocol for an individual patient data meta-analysis of randomized trials. Available from: http://bmjopen.bmj.com/ What is USSD (Unstructured Supplementary Service Data)? [Internet]. [cited 2022 Sep 24]. Available from: https://www.techtarget.com/searchnetworking/definition/USSD Macharia P, Pérez-Navarro A, Sambai B, Inwani I, Kinuthia J, Nduati R, et al. An Unstructured Supplementary Service Data–Based mHealth App Providing On-Demand Sexual Reproductive Health Information for Adolescents in Kibra, Kenya: Randomized Controlled Trial. JMIR Mhealth Uhealth. 2022;10(4). Oladele DA, Iwelunmor J, Gbajabiamila T, Obiezu-Umeh C, Okwuzu JO, Nwaozuru U, et al. An Unstructured Supplementary Service Data System to Verify HIV Self-Testing Among Nigerian Youths: Mixed Methods Analysis of Usability and Feasibility. JMIR Form Res. 2023 Jan 1;7(1). Digital 2020: Malawi — DataReportal – Global Digital Insights [Internet]. [cited 2022 Mar 17]. Available from: https://datareportal.com/reports/digital-2020-malawi Malanga DF. Implementing mobile health initiatives in Malawi: Current status, issues, and challenges. In: Health Information Systems and the Advancement of Medical Practice in Developing Countries. IGI Global; 2017. p. 115–28. Weiner BJ. A theory of organizational readiness for change. Implementation Science. 2009;4(1). Ahmed SK. The Pillars of Trustworthiness in Qualitative Research [Internet]. 2023. Available from: https://osf.io/se58y Nhavoto JA, Grönlund Å, Klein GO. Mobile health treatment support intervention for HIV and tuberculosis in Mozambique: Perspectives of patients and healthcare workers. PLoS One. 2017 Apr 1;12(4). Venables Id E, Ndlovu Z, Munyaradzi D, Martínez-Pé Rezid G, Mbofana E, Nyika P, et al. Patient and healthcare worker experiences of an HIV viral load intervention using SMS: A qualitative study. 2019; Available from: https://doi.org/10.1371/journal.pone.0215236 Macharia P, Pérez-Navarro A, Sambai B, Inwani I, Kinuthia J, Nduati R, et al. An Unstructured Supplementary Service Data–Based mHealth App Providing On-Demand Sexual Reproductive Health Information for Adolescents in Kibra, Kenya: Randomized Controlled Trial. JMIR Mhealth Uhealth. 2022 Apr 1;10(4). Odendaal WA, Anstey Watkins J, Leon N, Goudge J, Griffiths F, Tomlinson M, et al. Health workers’ perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis. Cochrane Database of Systematic Reviews. 2020;2020(3). Kruse C, Betancourt J, Ortiz S, Luna SMV, Bamrah IK, Segovia N. Barriers to the use of mobile health in improving health outcomes in developing countries: Systematic review. Vol. 21, Journal of Medical Internet Research. JMIR Publications Inc.; 2019. Using cellphones to deliver health services to teens: a sub-Saharan Africa review [Internet]. [cited 2024 Jun 14]. Available from: https://theconversation.com/using-cellphones-to-deliver-health-services-to-teens-a-sub-saharan-africa-review-182235 Zakerabasali S, Ayyoubzadeh SM, Baniasadi T, Yazdani A, Abhari S. Mobile health technology and healthcare providers: Systemic barriers to adoption. Healthc Inform Res. 2021 Oct 1;27(4):267–78. Clair-Sullivan NS, Mwamba C, Whetham J, Moore CB, Darking M, Vera J. Barriers to HIV care and adherence for young people living with HIV in Zambia and mHealth. Mhealth. 2019 Sep 1;5. Aljedaani B, Babar MA. Challenges With Developing Secure Mobile Health Applications: Systematic Review. JMIR Mhealth Uhealth [Internet]. 2021 Jun 1 [cited 2024 Jun 18];9(6). Available from: /PMC/articles/PMC8277314/ Zhou L, Bao J, Watzlaf V, Parmanto B. Barriers to and facilitators of using mobile health apps from a security perspective: Mixed-methods study. JMIR Mhealth Uhealth. 2019;7(4). Pankomera R, van Greunen D. A model for implementing sustainable mHealth applications in a resource-constrained setting: A case of Malawi. Electronic Journal of Information Systems in Developing Countries. 2018 Mar 1;84(2). Ngowi KM, Lyamuya F, Mmbaga BT, Muro E, Hillu Z, Shirima M, et al. Technical and psychosocial challenges of health usage for antiretroviral therapy adherence among people living with HIV in a resource-limited setting: case series. JMIR Form Res. 2020 Jun 1;4(6). Nurgalieva L, O’Callaghan D, Doherty G. Security and Privacy of mHealth Applications: A Scoping Review. IEEE Access. 2020;8:104247–68. Birnbaum F, Lewis D, Rosen RK, Ranney ML. Patient engagement and the design of digital health. Vol. 22, Academic Emergency Medicine. 2015. p. 754–6. Additional Declarations No competing interests reported. Supplementary Files Appendix1HealthCareWorkerIDIGuide20250520.docx Appendix2FocusGroupDiscussionGuideforALHIV20250520.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 13 Jun, 2025 Editor assigned by journal 11 Jun, 2025 Editor invited by journal 21 May, 2025 Submission checks completed at journal 20 May, 2025 First submitted to journal 20 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6669133","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":471036157,"identity":"1a6c56af-7403-402b-b3fc-44c0cbed8f60","order_by":0,"name":"Wapulumuka Joseph Masambuka","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIie3RLwvCQBzG8Z8OtOxYPRHfw2SwJO6teBzMclfNS2eyT4a+icFhFK4ObILMoAyWFBSTwX/L4lQshvv2D094AHS6/20OGAwFleA7UqNfE9P5jNhLlR3ObE3Gw+TkoFnHg7raVFeihKS+2xjJnEQmjylKfBKYvm3wEuKmPReQVGQKPFZIqB4AA4PLMtI/HS8FsXbZg9w8sHbvCLObxUqEmUGRmFcC/GbFS9mg2ZK5Mw5zpz0RlAic24pfX5NG1I+Pe7luhQua4b3oepZFtxlLXpPnalDcpNPpdLqfugPjK1dIZtYY3AAAAABJRU5ErkJggg==","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Wapulumuka","middleName":"Joseph","lastName":"Masambuka","suffix":""},{"id":471036158,"identity":"72edf3bf-92d4-4ae1-a551-4717586cfba8","order_by":1,"name":"Alinane Linda Nyondo-Mipando","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Alinane","middleName":"Linda","lastName":"Nyondo-Mipando","suffix":""}],"badges":[],"createdAt":"2025-05-15 05:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6669133/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6669133/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84872548,"identity":"6d4c59e7-5f0c-4672-8ef7-0877c8c71500","added_by":"auto","created_at":"2025-06-18 09:13:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":940625,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6669133/v1/4b688c19-7f20-4d2d-bef5-845d99fbe4bf.pdf"},{"id":84870602,"identity":"450a9b6a-f38b-4183-ab1f-cfb9d608114b","added_by":"auto","created_at":"2025-06-18 08:57:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":37484,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1HealthCareWorkerIDIGuide20250520.docx","url":"https://assets-eu.researchsquare.com/files/rs-6669133/v1/7694d230f0994fb33baf040c.docx"},{"id":84870597,"identity":"a3d73ee7-386c-46b9-9484-c5b416dd0925","added_by":"auto","created_at":"2025-06-18 08:57:52","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":36884,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2FocusGroupDiscussionGuideforALHIV20250520.docx","url":"https://assets-eu.researchsquare.com/files/rs-6669133/v1/53356ba9262dfeb79232eeea.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAssessing the Organizational Readiness in Using Unstructured Supplementary Service Data (USSD) to Improve Treatment Outcomes for Adolescents Living with HIV Transitioning to Adult Care at Umodzi Family ART Clinic\u003c/p\u003e","fulltext":[{"header":"1. Background","content":"\u003cp\u003eThe WHO reported that by 2019, over 1.7\u0026nbsp;million adolescents were living with HIV/AIDS, with 90% of the infection among those aged 15\u0026ndash;24 years (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Malawi, with an 8.9% HIV prevalence rate, has developed strategies in line with the 95-95-95 targets to join the global effort to end AIDS by 2030 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). According to the recent Malawi Population-based HIV Impact Assessment (MPHIA) survey, the country is on track to reach epidemic control (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, to sustain these gains, strengthening linkages to care and retention on antiretroviral Treatment (ART), particularly among younger adults, remains crucial (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Globally, Adolescents living with HIV (ALHIV) face significant challenges in accessing treatment and care, including poor retention, treatment adherence, low viral suppression, and loss of follow-up (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Few interventions exist to support ALHIV, with support groups being the primary intervention that has shown evidence to improve retention and adherence to treatment (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). To support ALHIV, the Malawi Ministry of Health uses the Teen Club model. The model offers ART treatment and psychosocial support and has contributed to improved adherence, retention, and viral load suppression (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The model is limited to ALHIV aged 10\u0026ndash;19 years, leaving adolescents transitioning to adult care without support. Evidence has shown that ALHIV patients transitioning to adult care face significant challenges, including a high loss to follow-up, poor adherence, and virological failure, exacerbated by structural system issues like lack of guidelines, staff training, and infrastructure (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). There is, therefore, a need to develop and implement interventions to support treatment outcomes for ALHIV transitioning to adult care. One of the interventions gaining traction in supporting patient treatment outcomes is Mobile health (mHealth). Evidence shows that mHealth is crucial in improving HIV/AIDS knowledge, adherence, retention, and psychosocial support (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Unstructured Supplementary Service Data (USSD) is a mobile communication protocol used in mHealth platforms, enabling real-time interaction through menu selections (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). USSD-based applications can be used offline on smartphones and regular phones and are provided free of charge to the user. Studies in adolescent health have shown that USSD-based applications offer an excellent platform for treatment support and improvement of health knowledge in low-resource settings (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMalawi has seen rapid mobile phone and USSD application usage growth, with mobile connections accounting for 51.4% of the population as of January 2022 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Despite challenges, the nation has effectively adopted mHealth applications to enhance healthcare and treatment outcomes (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Although the country's youth mobile phone usage is increasing, mHealth initiatives remain underutilized. mHealth solutions could improve treatment and health outcomes. Unfortunately, no known USSD-based interventions exist for ALHIV in the country. To understand the readiness in the usage of mHealth to support ALHIV transitioning to adult care. This study was conducted to assess the organizational readiness in using Unstructured Supplementary Service Data (USSD) to improve treatment outcomes For Adolescents Living with HIV transitioning to Adult Care at Umodzi Family ART Clinic. The results of the study have the potential to improve treatment outcomes for ALHIV transitioning to adult care.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Description of the Umodzi USSD for Adolescents App\u003c/h2\u003e \u003cp\u003eThe proposed application is a novel initiative under development to support ALHIV transitioning to adult care at the Umodzi Family. The author is developing the App with support from a software developer with experience in USSD-supported Applications. The App will utilize provider-based promptings through Short Messaging System (SMS) messaging and user-based prompting through access to the unique USSD code provided at a facility linked to the client's mobile number. Through password-protected logging into the USSD platform, a menu with critical themes will appear to prompt engagement with the user. The key themes will be developed based on the teen club curriculum that aims to improve treatment outcomes.\u003c/p\u003e \u003cp\u003eThe menu will prompt the user to access information on the key themes, including:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAdherence - Under this theme, key messaging on adherence will be accessed, and the user's next appointment dates will be displayed.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eViral load (VL) monitoring \u0026ndash; Key messages on VL monitoring, treatment failure, and routine VL monitoring milestones will be generated, and the next appointed dates for VL testing will be listed.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOpportunistic infections\u0026mdash;Key messages on common symptoms of opportunistic infections will be generated, along with typical symptoms and treatment options.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePsychosocial Support\u0026mdash;Key messages on psychosocial challenges will be generated, and the avenues for support will also be listed.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLinkage and referrals \u0026ndash; key links to support services will be listed.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eA toll-free number on each theme will be listed on the drop-down list to provide an option to speak to a health provider for further information and engagement. Engagements on the application will be stored on the facility's server.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Theoretical framework\u003c/h2\u003e \u003cp\u003eA theory of organizational readiness for change was used to assess the organizational readiness of the Umodzi family ART clinic to implement a USSD-based application to support treatment outcomes for ALHIV transitioning to adult care. The theory of organizational readiness looks at an organization\u0026rsquo;s members\u0026rsquo; shared resolve to implement a change (change commitment) through a shared collective capability to do so (change efficacy) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The following domains were assessed to assess the organizational readiness to implement an intervention: contextual factors, which examined the organizational culture that encourages innovation, risk-taking, and learning, flexible policies, and positive experiences with past changes and interventions. We also assessed change valence, which looked at the staff members' perceived value in the planned change due to its urgency, effectiveness, and anticipated benefits in supporting ALHIV transitioning to adult care. Lastly, change efficacy was also assessed to appraise the task demands the application would add to existing work and resource availability, including mobile access for the ALHIV. The theory was crucial in understanding the facility's readiness to use the application because it incorporated the identified facilitators and barriers in the critical constructs for the intervention to succeed.\u003c/p\u003e \u003c/div\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design\u003c/h2\u003e \u003cp\u003eThe novelty of the idea necessitated a qualitative exploratory study conducted from November 2023 to March 2024 to assess the organizational readiness for utilizing mHealth to enhance treatment outcomes for ALHIV transitioning to adult care, with healthcare staff and ALHIV transitioning to adult care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study Settings\u003c/h2\u003e \u003cp\u003eThe study was conducted at the Umodzi Family ART Clinic, Queen Elizabeth Central Hospital in Blantyre, Malawi. The facility is one of the largest ART centers in the country and is part of the Lighthouse Trust Centres of Excellence. The facility provides HIV testing, treatment, and care services. Patient data management is managed through an electronic records management system and a toll-free line to facilitate further engagement between healthcare workers and patients on treatment. As of May 2024, the facility had a cumulative register of over 40,000 patients, and with 16,000 currently alive and on treatment, 7% of those on treatment are young people aged 15\u0026ndash;24. Treatment and care are provided by the facility from Monday through Friday. Every Saturday, the Teen Club clinic offers care and support to adolescents living with HIV (ALHIV) aged 10 to 19. The clinic is overseen by health professionals, volunteers, and trained mentors. In addition to receiving medication, members of the Teen Club engage in a curriculum that covers various topics aimed at improving treatment outcomes and medication adherence. The club also provides peer support and psychosocial guidance for ALHIV. Each year, all HIV-positive individuals over the age of 19 are transitioned to adult care.\u003c/p\u003e \u003cp\u003eBefore transitioning, a readiness assessment is conducted, and those who qualify receive transition training to prepare for the adult clinic. Unfortunately, the loss of support from the teen clinic creates significant challenges for adolescents living with HIV (ALHIV) as they move into adult care. This transition often results in poor adherence to treatment, virological failure, and loss to follow-up, all of which are exacerbated by systemic issues such as inadequate infrastructure, insufficient staff training, and the lack of clear guidelines.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e2. 3 Sample Size and Selection of Participants\u003c/h3\u003e\n\u003cp\u003eParticipants were selected from the facility using a purposive sampling approach. We included participants aged 18 years and older, literate, and who had attended TC for more than three years, with access to a mobile phone. Gender, age, and phone ownership did not affect the selection to participate in the study. A database of recently transitioned ALHIV was used to identify potential participants. Phone calls were randomly made inviting ALHIV to participate in FGDs, while randomly selected health workers were approached and invited to participate in the In-depth Interviews. Thirty-two [32] participants participated in the study. Eight [8]) healthcare workers and support staff participated in the in-depth interviews, while twenty-four [24] ALHIVs participated in three [3] focus group discussions.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Collection\u003c/h2\u003e \u003cp\u003eThe framework guided the development of data collection tools (Appendices 1 and 2) based on the theory of organizational readiness. Healthcare workers at the Mangochi District Health Office pretested these tools, with no modifications made, and the pretest results were excluded from the main study. Data collection took place between December 2023 and January 2024, conducted by the author and a professional data collector. In-depth interviews (IDIs) were held in both Chichewa and English, while focus group discussions (FGDs) were conducted solely in Chichewa, lasting approximately thirty to forty-five minutes and including participants of various ages and genders. All interviews occurred in a secure office at the facility, convenient for interviewees, and were digitally recorded with notes as backup. Observations in the clinic assessed contextual factors related to service delivery. There were no follow-up interviews, and participants were not granted access to transcripts. No refusals to participate were recorded. The transcripts were reviewed daily to check for data saturation and sample size adequacy. Saturation was achieved by the 8th interview and the second FGD, but an additional FGD was held to include more participants and maintain gender balance.\u003c/p\u003e \u003cp\u003eTo ensure data credibility, we validated key points with participants, including adolescents in transition, nurses, clinicians, mentors, and psychosocial counsellors. We aimed for transferability and confirmability by providing a detailed description of the study setting and methods, creating an audit trail for others to follow.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data Management and Analysis\u003c/h2\u003e \u003cp\u003eAll interviews were audio recorded and carefully transcribed, except for those conducted in Chichewa, which were translated into English. The transcripts were stored on a password-protected PC and imported into NVivo 14 for data management and analysis. A qualified research assistant conducted the transcription, and WM double-checked them. The study PI developed the codebook using the theory of organizational readiness for change constructs as a guide. All transcripts were analysed using deductive analysis to identify codes linked to specific framework constructs. Identical and recurring codes were then categorized into themes per the study's objectives.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Ethics\u003c/h2\u003e \u003cp\u003e The Umodzi Family ART Clinic management and the Queen Elizabeth Central Hospital research committee approved the institutional request, and the College of Medicine Research and Ethics Committee (COMREC P.09/23\u0026ndash;0310) granted ethical approval. Written informed consent was obtained from all study participants before the interview and focus group discussions. Participation in the study was voluntary.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eNine medical professionals participated in the study, and twenty-four adolescents, with a median age of 19, attended the focus discussions. Every participant completed secondary education and had access to a mobile phone, with 87% having a personal phone.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of study participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Interview\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhone Access\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFDGs (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eALHIV With Access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eALHIV Without Access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic Characteristics of Health Care Workers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Interview\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of Participants\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConstructs and Themes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstruct Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eChange Valance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePotential to improve treatment, provide vital information, and enhance retention, adherence, and viral suppression.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo significant barrier was identified.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnhancing knowledge on treatment for ALHIV transitioning to adult care is crucial for the enhancement of treatment outcomes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eChange Efficacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTask Demands\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo extra task demands on Clinical team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExtra demands to burden the ICT Team\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eResource availability\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh mobile phone access for the ALHIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRestriction to access for platforms supports the application\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEssential Resources Available (i.e., hotline, servers, and personnel)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSituational factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeed for engagement for ALHIV Post-Teen Club to improve outcomes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReservations On Security\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eApplication to alleviate logistical challenges in accessing vital information\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eContextual factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eOrganizational culture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrevious Positive Experience with mHealth Application.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNegative experiences with the use of mHealth Application\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperience with using other USSD Platforms\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePolicies and Procedures\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAvailability and awareness of mHealth-related policies and procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGaps in the availability and staff awareness of mHealth Related Policies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eApp Desing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeed for additional themes to the drop-down list.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUsability Fears\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Change Valance: Opportunity to optimize treatment\u003c/h2\u003e \u003cp\u003eThe term \"change valence\" describes how prepared an organization is for change, with members embracing planned changes due to the urgency, efficacy, and potential benefits (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The USSD application was deemed appealing to ALHIV and healthcare workers due to its potential to enhance treatment, provide essential information, and promote retention, adherence, and viral suppression. Both healthcare workers and ALHIV felt that the application would provide easy access to information on side effects, appointment dates, and next viral load milestone dates, which are vital to enhancing treatment outcomes. In addition, the participants felt that adopting the application would reduce structural barriers like waiting times and distance.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;This platform is good, over time, because it will save time and improve treatment outcomes. You see most of the problems that we've got, especially when it comes to men and boys; they don't have that interest in coming to the facility most of the time because they are ok, and the time they are presented to the facility, they are presenting at an advanced stage, so with this kind of facility, they will even improve the prognosis of opportunistic infections and the treatment outcomes might also be quite well managed with this kind of platform\u0026rsquo; \u0026ndash; Clinical Officer 2.\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It is useful because we may forget the date of appointment to visit the facility, you may easily check on the App and get the response, unlike not knowing the date you may think of just visiting the facility anyhow\u0026rdquo;- Adolescent 1\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;This App will close that gap (information on enhancing their treatment outcomes). Since they are growing up, they will need to be searching and getting information. This App will make sure that they are getting the correct information. So, if they have something, they will say, let me go to the App and see what information it is. - Data Manager\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Change Efficacy: Task demands, Resource Availability, and Situational factors.\u003c/h2\u003e \u003cp\u003eChanging efficacy is a key component of change implementation, based on how cognitively organizational members assess task demands, resource availability, and situational factors (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). To determine the change efficacy, we evaluated the task demands, resource availability, and situational factors to see if the facility was prepared to implement the intervention to enhance outcomes for ALHIVs transferring to adult care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Staff Task Demands\u003c/h2\u003e \u003cp\u003eFirst, we sought to determine whether task demands would change because of the application's launch. The main emphasis of our assessment was whether the intervention would create bottlenecks or enhance regular tasks. The clinical participants who were interviewed all expressed that the intervention would not lead to additional task demands that would negatively impact the way operations are conducted at the facility.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;If this adolescent did not have the information that he had gotten from the App, either they were supposed to call me, or they were supposed to come to the clinic. That will result in extra work, but they will not come to me if they have that information at home. At least, they will only come to me when there is probably somewhere where they don't understand. I will only explain where they did not understand, than narrating the whole story\u0026rsquo; -\u003c/em\u003e Clinical Officer 1\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIt was additionally stated that the intervention would provide an additional level of assistance to assist ALHIV patients transitioning to adult care. Based on our observations, the clinic was rather busy and heavily overcrowded, making it difficult for nurses and doctors to engage participants for extended periods. Due to the congestion, the drug-collecting process took approximately two to three hours. These sentiments were backed by the healthcare workers working at the facility.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;As previously stated, individuals may have inquiries but refrain from asking or receiving the desired response. As you can see today, a few clinical rooms are operational, which increases the waiting time. So for the person to ask more questions, they'll be like, hey, I'll be delaying people outside, so I can't ask the question. But if they have a platform where they can ask things or want to know about the viral load challenges, sometimes the patient will come, and then you fail to give them the result. And then they go home. I'm like, ah, they didn't give me my results. They can easily check\u0026rsquo;-\u003c/em\u003e Nurse 1\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Resource availability\u003c/h2\u003e \u003cp\u003eResources for the proposed change are another essential factor in determining the readiness for change. In addition to the intervention's need to function within the current platforms, resources supporting the change are crucial for the intervention to be successful. Adolescents' access to mobile phones was critical to the intervention's success. We assessed the adolescents' access to mobile phones and found that, of the 24, 20 had a personal phone, and the other 4 had unrestricted access to their guardians' phones.\u003c/p\u003e \u003cp\u003eFurthermore, we explored the accessibility of hotlines, computer servers, and networks\u0026mdash;all required for the intervention. The facility could support the application because it managed its local network and had an operational hotline, which are essential to its success.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;We already have a hotline where clients can call using that line. For IT facilities, I think we've got a good one; the network is not an issue, and maintaining the application, I believe, has to do with the application developer working hand in hand with the IT guys, which we already have. -\u003c/em\u003e Clinical Officer 2\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOn the other hand, it was contended that for the application to be effective, it had to interface with current platforms and systems. The application's architecture should be interoperable with existing platforms to prevent duplication of work and system isolation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;It must work with the already-existing systems. This means that you must thoroughly assess the existing systems. And then you see how this one will blend in with what's already on the ground. How will the application blend into the already existing system? And the already existing resources. That's why I think I mentioned cost-effectiveness and efficiency as well. To lessen the burden, make it more; if you do, it should improve the system or application\u0026rsquo;. -\u003c/em\u003e Data Manager\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Situational factors\u003c/h2\u003e \u003cp\u003eSituational factors also influence the efficacy of change. Examples of situational factors are the time required to accomplish a change and other aspects of the internal and external environments that facilitate a planned change. One of the most critical situational factors crucial for improving treatment outcomes for AIDS is the need for ongoing engagement with ALHIV as the transition to adult care. ALHIV and healthcare providers underscored the importance of continuing engagement to ease the transition and improve treatment outcomes.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;They (ALHIV) develop a high viral load after graduating. This means that in adult care, something is lacking in this team, which was being managed when they were at the teen club. Then, the way we do it\u0026mdash;leave them\u0026mdash;has also shown that when they were adolescents, their viral load suppression or retention was good, but the moment they transition out, you can see that it's not good-\u003c/em\u003e Nurse 2\u003c/p\u003e\u003cp\u003e \u003cem\u003eSince we are now in adult care, the interval between taking the drugs will be longer than before. We were receiving them at two monthly intervals; now, it is six months, so it is challenging to maintain drug adherence. They are supposed to call us at some point to remind us \u0026ndash;\u003c/em\u003e Adolescent 4\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdjustments made to the intervals between clinic visits (three months to six months) due to transition made it apparent that to guarantee maximum adherence and viral suppression, a platform would be necessary to regularly remind adolescents about clinic appointments and viral load testing milestones, which are critical for good treatment outcomes. It was anticipated that the application would help adolescents get regular reminders about clinic appointments and viral load milestones.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIt (the application) is helpful because we may forget the date of the appointment to visit the facility, you may easily ask and get the response on the App, unlike not knowing the date, you may think of just visiting the facility anyhow. \u0026ndash;\u003c/em\u003e Adolescent 5\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;They can just go on the USSD app and access information. You also mentioned that there might be an update regarding their viral load so they can check, and if they've got a high viral load, there should be some of the information already there that should assist them in working around their issues with viral load and adherence before they come to the clinic -\u003c/em\u003e Clinical Officer 1\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eNonetheless, adolescent concerns about security and privacy were identified as one of the main obstacles to the application's successful implementation. Unintentional disclosure can result in the stigmatization of those living with HIV, which is still one of the issues in the care of HIV patients.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;The challenge is that some friends may come and check what you are doing on the phone, and you get to realize too late that he or she has read what I was doing.' \u0026ndash;\u003c/em\u003e Adolescent 7\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;So, let\u0026rsquo;s assume that you have opened the Application with your PIN, but you have forgotten and just left a phone somewhere; how long will the message be displayed?'. \u0026ndash; Adolescent 12\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Contextual factors\u003c/h2\u003e \u003cp\u003eThe organization's readiness for change can be impacted by contextual factors, such as a culture that values creativity, risk-taking risks, learning, flexible regulations and processes, a healthy workplace culture, and a positive experience with change. These contextual factors were also assessed to determine the facility's readiness in implementing the application.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Organizational culture\u003c/h2\u003e \u003cp\u003eWe were particularly interested in the facility's positive experiences with mobile health platforms. To do so, we assessed the facility's prior successes in utilizing mHealth platforms. The electronic patient management systems at the facility were found to be operational, and the toll-free hotline was found to be an effective tool for patient engagement.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;One of the major successes of mobile technology for the facility is that we're able to retain clients through our hotline number. Clients travel but don't know where to go or how to get the medication, and then they will call us, and we guide them. We say they go to the closest facility, where they are assisted, and then we update their file to say they're still taking medication\u0026rsquo;\u003c/em\u003e \u0026ndash; Clinical Officer 2\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Just to give you an example, we've got a program for people staying in the diaspora. We've got a digital platform with an app whereby if someone goes outside Malawi when they get the medication, we scan them. We put them into that system in the event they go somewhere else, and then someone is trying to ask about their medication. What we do is check on the batch number, we go online, and then we verify this is coming from us, so we've got those kinds of already existing policies that are promoted in this kind of \u0026ndash;\u003c/em\u003e Clinical Officer 2\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDespite the successes registered, some applications have had challenges. One of the reasons for the failure of mHealth applications was the lack of interest among health workers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Sometime back, we had an app that was assigned to the pharmacy; that app did not go well because there was no interest in the application.' \u0026ndash;\u003c/em\u003e Nurse 3\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.8 Policies and Procedures\u003c/h2\u003e \u003cp\u003ePolicies have a critical role in implementing change. Thus, policies and processes ought to support change. To facilitate the mHealth-related interventions, we explored whether the facility had the requisite policies and procedures. Among the policies considered crucial for the application's success included privacy, security, and patient data protection policies.\u003c/p\u003e \u003cp\u003eThe study, therefore, sought to determine whether the participants were aware of policies and procedures to support mHealth efforts. Unfortunately, all the staff interviewed were unaware of any mHealth-related policies and referred us to the data manager, based at the facility headquarters in another city.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;\u003cem\u003eWell, on that one, I'm not so sure about that. I think the IT personnel should better answer that; they should have plans for that \u0026ndash;\u003c/em\u003e Tracer 2\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurthermore, most respondents indicated that the facility's patient confidentiality policy was one of the most critical components of managing patient data and confidentiality. It was also reported that the institution had strong safety measures for patient-level data and digital health platforms, even without mHealth policies.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;\u003cem\u003eOur systems are secured. Even the EMR we're talking about. The providers have their password, username, and password. It's all part of patient-level security and data security \u0026ndash;\u003c/em\u003e Data Manager\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.9 Application Design\u003c/h2\u003e \u003cp\u003eA recurrent theme around the application's design was identified during the data analysis. This theme stood out because it did not fit with the initial themes developed for the study. Furthermore, we needed to highlight the importance of the design features and usability of the application, which are crucial for its success. Several areas around design stood out, and one of the areas that registered highly in the IDI was the need for additional themes on the menu. Sexual Reproductive Health (SRH), Pre-Exposure Prophylaxis (PrEP), and drug monitoring were some of the critical areas that were suggested by both the healthcare workers and ALHIV.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eOn the part of other services, the linkage should be there; issues related to SRH are some information they lack. Even the referral is essential if possible; most adolescents are just about to get pregnant, which means that family planning concerns aren't well taken care of. They even fail to protect their lovers with PREP because they don't have that information. If it is possible, include it\u003c/em\u003e \u0026ndash; Nurse 3\u003c/p\u003e\u003cp\u003e\u003cem\u003eAnother thing to add is a drug monitoring tool, where we can be able to know how many drugs are remaining and when I will be visiting the facility to meet the nurse. \u0026ndash;\u003c/em\u003e Adolescent 8\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSecondly, the functionality and usability of the application were a notable factor for the success of the intervention. ALHIV and healthcare workers stressed the need to ensure the system was user-friendly and efficient.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI think another thing should be that you ensure that the system doesn't crash because it's a beautiful thing, but then if it's a thing that keeps on crashing, it won't save the purpose of reaching out to them. \u0026ndash;\u003c/em\u003e Clinical Officer\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdolescents also argued for needing healthcare workers with experience working with adolescents. Since most adolescents have previously worked with a group of trained mentors, it was argued that they need to continue with a similar group of professionals to manage the application and the hotline.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe can't be open to everybody to say something, so when calling, if it is possible, choose one to talk with. Will that be possible? -\u003c/em\u003e Adolescent 11\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe IDIs with the healthcare workers also reemphasized the need to have people with interest and experience in working with adolescents as part of the team to manage the application. Having a team of health workers with experience in working with ALHIV will ensure a better understanding of the needs of the ALHIV.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe need to have people who are interested in this. If you approach the mentors, they are already interested in adolescents. Those people are the ones to be at the forefront. So, adolescents should not take time if they ask for something. Most of the time, when they are asking for something, they have a challenge that needs to be addressed promptly. So, there is a need to say that these people, on this end, must have an interest, need to have an interest, and two must know the adolescent behavior, status, and needs. \u0026ndash;\u003c/em\u003e Nurse 3\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe study's main findings demonstrate that adolescents and healthcare professionals were willing to use the application to improve treatment outcomes as they transitioned to adult care. Secondly, our findings also highlight the importance of the intervention in continuing engagement during the transition to adult care, which is critical for ALHIV. We also found that implementing the application would not have a detrimental effect on the tasks that healthcare workers were anticipated to perform. Furthermore, the facility's previous experience with mHealth applications and the availability of resources was seen as a significant facilitator to the success of the application. Mobile phone access was also highlighted as an essential facilitator of the application, with all adolescents who participated in the study having mobile phone access. However, interoperability and design concerns likely hindered the application's implementation and required addressing for the App to operate effectively.\u003c/p\u003e \u003cp\u003eBoth healthcare workers and ALHIV acknowledged that the application was essential in enhancing treatment outcomes in transitioning to adult care. Participants felt that the application would help provide appointment reminders and access to vital information that is key to improving treatment outcomes. This resonates with other studies showing healthcare workers' and patients' perceived appreciation of mHealth applications' role in reducing missed appointments, improving communication between healthcare providers and patients, and assisting in education and motivation. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA study in Zimbabwe revealed that healthcare workers considered a Viral Load SMS intervention essential for improving patient adherence and managing Viral health facilities (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). A USSD-based application study among adolescents in Kenya showed that USSD-based applications are critical to improved decision-making regarding sexual reproductive health (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe results further demonstrate that the introduction of mHealth applications improves the clinical management of patients and enhances service delivery without adversely affecting task demands. Results from a qualitative evidence synthesis on Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare service revealed that mHealth applications improved the work flexibility, task-taking, and engagement of clients in challenging locations. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The synthesis further found that healthcare workers valued improved feedback and the speed of workflow that mHealth applications presented.\u003c/p\u003e \u003cp\u003eThe study further found that a toll-free hotline at the facility and the availability of already-existing ICT platforms were significant facilitators to the application's success. Studies have shown that a lack of infrastructure is one of the biggest obstacles to the adoption and long-term viability of mHealth applications in many low-resource settings. A systematic review on barriers to using mobile health in improving health outcomes in developing countries found that lack of infrastructure and equipment were among the top barriers to implementing mHealth Interventions. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The availability of the said resources at the facility presents a significant opportunity for the application's success.\u003c/p\u003e \u003cp\u003eAdditionally, we discovered that almost all the study's adolescent participants had access to mobile phones, which was a crucial cog in implementing the application. Furthermore, we also found high access to a mobile phone among adolescents in the study presented a significant building block for rolling out the application. The Sub-Saharan Africa (SSA) region has a considerable opportunity to improve health outcomes, especially HIV treatment adherence, as evidence suggests that the region's mobile phone penetration is increasing. Evidence further shows that adolescents are utilizing mHealth to support health outcomes. A systematic review of mobile health interventions for young people found they effectively improved contraceptive use, sexual health knowledge, and HIV treatment adherence (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother prerequisite for guaranteeing the App's success was its integration with already-existing applications. Participants underscored the need for integration with existing platforms to ensure success. Research demonstrates that most mHealth interventions fail due to challenges around integration and interoperability. Interoperability refers to the ability of information systems, devices, and applications to access, exchange, and integrate health data between multiple organizations, systems, or care settings. Evidence indicates that a lack of interoperability in new interventions is one of the significant barriers to providers because of the burden of their work processes and healthcare costs (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). For the application to succeed, it must integrate with existing platforms, including the facility's electronic patient management systems and networks, to ensure efficiency and effectiveness.\u003c/p\u003e \u003cp\u003eOur results further suggest that continued engagement with ALHIV is necessary to improve a seamless transition from adolescent to adult care, which is crucial to achieving better treatment results. Health professionals and teenagers alike were enthusiastic about the application as they believed it would be helpful to the engagement of ALHIV transitioning to adult care. Transitioning to adult HIV care continues to be riddled with challenges, and there is a need for interventions that would enhance engagement between healthcare workers and adolescents. Both healthcare workers and ALHIV felt the application would provide appointment reminders and vital information for treatment outcomes. In other settings, evidence has shown that mHealth presents an excellent avenue to support treatment outcomes for people in HIV care and has the potential to improve outcomes and retention in YPLHIV (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOn the other hand, privacy was highlighted as one of the major fears in implementing the application. Adolescents were worried about unintentional disclosure to friends and asked for more robust security measures to safeguard their privacy. This aligns with the literature showing that most healthcare workers and patients share concerns about privacy and security. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). One way to address the privacy and security gaps is through policies and frameworks to guide mHealth intervention. Unfortunately, apart from the patient confidentiality procedures at the facility, all participants interviewed were unaware of the policy framework guiding mHealth interventions at the facility. Other findings have shown that poor policy and regulations remain one of the biggest obstacles to the scalability and sustainability of mHealth in the country (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo overcome this gap in policy implementation, mHealth developers must ensure that applications have security features and means to prevent unintentional disclosure. One way to address unintended disclosure includes using neutral messaging that refrains from discussing health-related or medication-related topics (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Access control and authentication provide another alternative to ensure that privacy is maintained. Unfortunately, it is still difficult to verify if the intended recipient is using the application on the other end (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLastly, our findings show that it was vital to consider user demands in the application's design and usability. Aside from ensuring the application was user-friendly, participants felt it necessary to include additional topics in the drop-down menu, including SRH, PrEP, and drug monitoring. Evidence has demonstrated that challenges with usability and a lack of patient or user engagement in the design process contribute to the low uptake of mHealth interventions (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). User engagement is, therefore, pivotal in designing and implementing mHealth Applications. It is crucial to engage the ALHIV and health care workers in the design of the application to ensure its success in enhancing treatment outcomes for ALHIV transition to adult care.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Strengths and Limitations of the Study\u003c/h2\u003e \u003cp\u003eThe study's main strength is that it involved the ALHIV and healthcare workers, the intended primary users of the application. However, it is also important to point out the study's limitations considering the findings. First, the study was conducted in an urban facility with already present platforms and systems that could promote mHealth, which may not be the same in other facilities. In addition, most of the ALHIV population interviewed were from urban settings, and mobile phone penetration may not be transferable to other rural settings.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe study findings demonstrate a readiness in the facility to use and adopt the application to support treatment outcomes for the ALHIV transitioning to adult HIV care. Both ALHIV and healthcare workers are willing to use the application. The application was deemed essential in providing reminders and vital information key to the treatment and care of HIV. Facilitators for the successful application implementation include high mobile access among adolescents, availability of the ICT platforms and the toll-free line present, and the facility\u0026rsquo;s past success with other mHealth platforms. However, for this to be achieved, the privacy and security of the application must be enhanced. The application's effectiveness also depends on the engagement of health professionals and ALHIV in the development process. These findings add to the organization's readiness for mHealth interventions and offer significant insights on mHealth applications for ALHIV transitioning to adult care and enhancement of treatment outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Umodzi Family ART Clinic management and the Queen Elizabeth Central Hospital research committee approved the institutional request, and the College of Medicine Research and Ethics Committee (COMREC P.09/23-0310) granted ethical approval. Written informed consent was obtained from all study participants before the interview and focus group discussions. \u0026nbsp;Participation in the study was voluntary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable as no datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eU.S. President\u0026rsquo;s Emergency Plan for AIDS Relief, U2GGH002173\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWM developed the protocol, conducted the data analysis and wrote the manuscript. ANM guided the protocol development, data analysis and \u0026nbsp;the manuscript writing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the staff and clients at the Umodzi family ART Clinic for their support during study and the Malawi HIV Implementation Research Scientist (MHIRST) Training Program the for support and mentorship\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYoung people and HIV. \u003c/li\u003e\n\u003cli\u003eNational Strategic Plan for HIV and AIDS 2020-25 Final. \u003c/li\u003e\n\u003cli\u003eMalawi Population-based HIV Impact Assessment 2020-2021 Malawi Population-based HIV Impact Assessment MPHIA 2020-2021. Available from: http://phia.icap.columbia.edu\u003c/li\u003e\n\u003cli\u003eMalawi Excels on UNAIDS 95-95-95 Treatment and Viral Suppression Targets - EGPAF [Internet]. [cited 2022 Jun 7]. Available from: https://pedaids.org/resource/malawi-excels-on-unaids-95-95-95-treatment-and-viral-suppression-targets/\u003c/li\u003e\n\u003cli\u003eAdolescent and young adult health [Internet]. [cited 2022 Mar 15]. Available from: https://www.who.int/news-room/fact-sheets/detail/adolescents-health-risks-and-solutions\u003c/li\u003e\n\u003cli\u003eMackenzie RK, van Lettow M, Gondwe C, Nyirongo J, Singano V, Banda V, et al. 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JMIR Form Res. 2020 Jun 1;4(6). \u003c/li\u003e\n\u003cli\u003eNurgalieva L, O\u0026rsquo;Callaghan D, Doherty G. Security and Privacy of mHealth Applications: A Scoping Review. IEEE Access. 2020;8:104247\u0026ndash;68. \u003c/li\u003e\n\u003cli\u003eBirnbaum F, Lewis D, Rosen RK, Ranney ML. Patient engagement and the design of digital health. Vol. 22, Academic Emergency Medicine. 2015. p. 754\u0026ndash;6. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescents Transitioning to Adult Care, Mobile Health, Unstructured Supplementary Service Data (USSD), Treatment Outcomes, HIV/AIDS, Organization Readiness, Digital Health","lastPublishedDoi":"10.21203/rs.3.rs-6669133/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6669133/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eAdolescents living with HIV (ALHIV) face challenges transitioning to adult care. Mobile health interventions, particularly Unstructured Supplementary Service Data (USSD), have effectively improved HIV knowledge and treatment outcomes. While mobile penetration in Malawi has increased, there are no USSD interventions specifically for ALHIV. A proposed USSD application aimed to enhance treatment outcomes for this group. This study evaluated the organizational readiness of the Umodzi Family ART Clinic to implement this platform.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e This qualitative exploratory study was conducted between November 2023 and March 2024 at the Umodzi Family Clinic in Blantyre, Malawi, focusing on healthcare workers and ALHIV transitioning to adult care. We conducted nine in-depth interviews with healthcare professionals and facilitated three focus group discussions with thirty-two ALHIV participants. All interviews and focus group sessions were recorded, transcribed verbatim, and analysed using NVivo 14 software, guided by the theory of organizational readiness to identify key themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOur findings indicate a strong willingness among both ALHIV and healthcare workers to use the application to improve treatment outcomes during the transition to adult care. Key features like access to treatment information and reminders were recognized as vital for enhancing adherence, retention, and viral suppression. The presence of digital platforms at the facility, widespread mobile access among ALHIV, and the facility\u0026rsquo;s prior experience with digital health initiatives were major facilitators for the App's success. Nevertheless. enhancements in privacy, security, interoperability, and overall app design were highlighted as critical features for successful app adoption.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe findings demonstrate a significant readiness to embrace the proposed application to enhance treatment outcomes. Additionally, our results underscore essential pillars of organizational readiness that are vital in designing and implementing mHealth applications. The study's results are critical for developing and implementing USSD applications to support treatment outcomes for ALHIV transitioning to adult care.\u003c/p\u003e","manuscriptTitle":"Assessing the Organizational Readiness in Using Unstructured Supplementary Service Data (USSD) to Improve Treatment Outcomes for Adolescents Living with HIV Transitioning to Adult Care at Umodzi Family ART Clinic","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-18 08:57:47","doi":"10.21203/rs.3.rs-6669133/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-06-13T07:13:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-11T10:13:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-21T09:23:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-20T19:48:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-20T19:47:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"54d9dd35-1d49-40cc-9215-c594ffa10f6d","owner":[],"postedDate":"June 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-18T08:57:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-18 08:57:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6669133","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6669133","identity":"rs-6669133","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}