Consent for mobile phone surveys of non-communicable disease risk factors in low-resource settings: an exploratory qualitative study in Uganda

An open-source digital contact tracing system tailored to haulage

Digital contact tracing presents numerous advantages compared to manual contact tracing methods, especially in terms of enhanced speed and automation. Nevertheless, a lack of comprehensive evaluation regarding functionality, efficiency, benefits, and acceptance within communities remains. Here we primarily focus on the functionality of THEA-GS, an open-source digital contact tracing tool developed through consultation with stakeholders. Additionally, we provide insights from its implementation on a limited sample of haulage drivers in Uganda, serving as a representative case for a low- and middle-income country. THEA-GS comprises two primary components: (a) a smartphone application, and (b) a suite of server-programs responsible for data processing and analysis, including databases and a web-based interface featuring dashboards. In essence, the mobile application records the timestamped location of haulage drivers within the road network and identifies possible transmission hotspots by analyzing factors such as the duration of stops and the communities associated with them. The tool can be integrated with national infrastructure to compare drivers' diagnostic results and contact structure, thereby generating individual and community risk assessments relative to the road network. During the Omicron-variant wave of the COVID-19 pandemic, a total of 3,270 haulage drivers were enrolled between October 2021 and October 2022. Around 75% of these drivers utilized THEA-GS for approximately two months. Based on an analysis of 3,800 test results, which included 48 positive cases, 125 contacts, and 40 million time-stamped GPS points, THEA-GS shows a significant speed improvement, being approximately 90 times faster than MCT. For instance, the average time from sample collection to notifying a case and their contacts was approximately 70 and 80 min, respectively. The adoption of this tool encountered challenges, mainly due to drivers' awareness of its purpose and benefits for public health. THEA-GS is a place-based digital contact tracing tool specifically designed to assist National Public Health Institutions in managing infectious disease outbreaks involving the haulage industry as a high-risk group. While its utility, acceptance, and accuracy have not been fully evaluated, our preliminary tests conducted in Uganda indicate the tool's functionality is robust, but social acceptance and adoption are heavily reliant on establishing trust among users.

Remote consent approaches for mobile phone surveys of non-communicable disease risk factors in Colombia and Uganda: A randomized study

INTRODUCTION

Automated mobile phone surveys (MPS) can be used to collect public health data of various types to inform health policy and programs globally. One challenge in administering MPS is identification of an appropriate and effective participant consent process. This study investigated the impact of different survey consent approaches on participant disposition (response characteristics and understanding of the purpose of the survey) within the context of an MPS that measured noncommunicable disease (NCD) risk factors across Colombia and Uganda.

METHODS

Participants were randomized to one of five consent approaches, with consent modules varying by the consent disclosure and mode of authorization. The control arm consisted of a standard consent disclosure and a combined opt-in/opt-out mode of authorization. The other four arms consist of a modified consent disclosure and one of four different forms of authorization (i.e., opt-in, opt-out, combined opt-in/opt-out, or implied). Data related to respondent disposition and respondent understanding of the survey purpose were analyzed.

RESULTS

Among 1889 completed surveys in Colombia, differences in contact, response, refusal, and cooperation rates by study arms were found. About 68% of respondents correctly identified the survey purpose, with no significant difference by study arm. Participants reporting higher levels of education and urban residency were more likely to identify the purpose correctly. Participants were also more likely to accurately identify the survey purpose after completing several survey modules, compared to immediately following the consent disclosure (78.8% vs 54.2% correct, p<0.001). In Uganda, 1890 completed surveys were collected. Though there were differences in contact, refusal, and cooperation rates by study arm, response rates were similar across arms. About 37% of respondents identified the survey purpose correctly, with no difference by arm. Those with higher levels of education and who completed the survey in English were able to more accurately identify the survey purpose. Again, participants were more likely to accurately identify the purpose of the survey after completing several NCD modules, compared to immediately following the consent module (42.0% vs 32.2% correct, p = 0.013).

CONCLUSION

This study contributes to the limited available evidence regarding consent procedures for automated MPS. Future studies should develop and trial additional interventions to enhance consent for automated public health surveys, and measure other dimensions of participant engagement and understanding.

Ethical considerations of phone-based interviews from three studies of COVID-19 impact in Bihar, India

Phone-based interviews present a range of ethical challenges, including how to ensure informed consent and privacy and maintain confidentiality. Our paper presents conceptual and practical ethical considerations taken into account across three telephone studies on the impact of COVID-19 conducted following India’s nationwide lockdown imposed in March 2020. Two studies captured COVID-19 response impact on primary-level Reproductive Maternal Neonatal and Child Health (RMNCH) services and on provider wellness, respectively. The third study focused on how the gendered experience of COVID-19 and the state’s response to control transmission impacted women’s lives, focusing on health services, livelihood, entitlements and social change, by interviewing individual women. The ethical challenges as well as the advantages of digital data collection are presented with recommendations for low-resource settings. Ethical considerations included the above challenges as well as avoiding posing unreasonable time burden on the respondents, framing questions with a gendered lens, considering emotional states given contagion concerns and economic uncertainties, and redressing pandemic-induced distress. Using scripted Hindi was challenging in consent-taking, as was protecting household respondents’ privacy and confidentiality during lockdown. Unanticipated positive ethical implications of using a telephone approach included providing respondents privacy and catharsis, respondents choosing convenient interview times and affording health providers more privacy than institutional inperson interviews. Internalising empathy, respect and appreciative enquiry are key to establishing rapport in the absence of prior relationships. Institutional Review Board (IRB) time limits on call duration need to be flexible to allow for ‘active listening’ and empathetic enquiry in surveys on the impact of COVID-19.

Adaptation of a mobile phone health survey for risk factors for noncommunicable diseases in Colombia: a qualitative study

Background

Data collection on noncommunicable disease (NCD) behavioral risk factors has traditionally been carried out through face-to-face surveys. However, its high costs and logistical difficulties can lead to lack of timely statistics for planning, particularly in low and middle-income countries. Mobile phone surveys (MPS) have the potential to fill these gaps.

Objective

This study explores perceptions, feasibility and strategies to increase the acceptability and response rate of health surveys administered through MPS using interactive voice response in Colombia.

Method

A sequential multimodal exploratory design was used. We conducted key informant interviews (KII) with stakeholders from government and academia; focus group discussions (FGDs) and user-group tests (UGTs) with young adults and elderly people living in rural and urban settings (men and women). The KII and FGDs explored perceptions of using mobile phones for NCD surveys. In the UGTs, participants were administered an IVR survey, and they provided feedback on its usability and potential improvement.

Results

Between February and November 2017, we conducted 7 KII, 6 FGDs (n = 54) and 4 UGTs (n = 34). Most participants consider MPS is a novel way to explore risk factors in NCDs. They also recognize challenges for their implementation including security issues, technological literacy and telecommunications coverage, especially in rural areas. It was recommended to promote the survey using mass media before its deployment and stressing its objectives, responsible institution and data privacy safeguards. The preferences in the survey administration relate to factors such as skills in the use of mobile phones, age, availability of time and educational level. The participants recommend questionnaires shorter than 10 minutes.

Conclusions

The possibility of obtaining data through MPS at a population level represents an opportunity to improve the availability of risk-factor data. Steps towards increasing the acceptability and overcoming technological and methodological challenges need to be taken.

User Perceptions and Experiences of an Interactive Voice Response Mobile Phone Survey Pilot in Uganda: Qualitative Study

Background

With the growing burden of noncommunicable diseases in low- and middle- income countries, the World Health Organization recommended a stepwise approach of surveillance for noncommunicable diseases. This is expensive to conduct on a frequent basis and using interactive voice response mobile phone surveys has been put forth as an alternative. However, there is limited evidence on how to design and deliver interactive voice response calls that are robust and acceptable to respondents.

Objective

This study aimed to explore user perceptions and experiences of receiving and responding to an interactive voice response call in Uganda in order to adapt and refine the instrument prior to national deployment.

Methods

A qualitative study design was used and comprised a locally translated audiorecorded interactive voice response survey delivered in 4 languages to 59 purposively selected participants' mobile phones in 5 survey rounds guided by data saturation. The interactive voice response survey had modules on sociodemographic characteristics, physical activity, fruit and vegetable consumption, diabetes, and hypertension. After the interactive voice response survey, study staff called participants back and used a semistructured interview to collect information on the participant’s perceptions of interactive voice response call audibility, instruction clarity, interview pace, language courtesy and appropriateness, the validity of questions, and the lottery incentive. Descriptive statistics were used for the interactive voice response survey, while a framework analysis was used to analyze qualitative data.

Results

Key findings that favored interactive voice response survey participation or completion included preference for brief surveys of 10 minutes or shorter, preference for evening calls between 6 PM and 10 PM, preference for courteous language, and favorable perceptions of the lottery-type incentive. While key findings curtailing participation were suspicion about the caller’s identity, unclear voice, confusing skip patterns, difficulty with the phone interface such as for selecting inappropriate digits for both ordinary and smartphones, and poor network connectivity for remote and rural participants.

Conclusions

Interactive voice response surveys should be as brief as possible and considerate of local preferences to increase completion rates. Caller credibility needs to be enhanced through either masking the caller or prior community mobilization. There is need to evaluate the preferred timing of interactive voice response calls, as the finding of evening call preference is inconclusive and might be contextual.