Tuesday, May 13, 2014

The Prevention of Women to Child HIV transmission: A Critique of Cell phone SMS messaging in South Africa – Anonymous

The HIV virus is a growing epidemic in South Africa. According to The Joint United Nations Programme on HIV and AIDS (UNAID) in 2011 5.6 million people living in South Africa carried HIV (16). HIV prevalence rapidly grew from 1990-2001 (17) causing more deaths and a bigger public health concern. The increase of HIV across South Africa in 2001 changed from 15.3% to 17.3% in 2012 (17). The spread of HIV continues to increase with transmission from mother to child (1-5). An estimated 360,000 children became infected by their mothers either during pregnancy, birth or breastfeeding in 2010 (7). Children under the age of five have a higher risk of death (1).  Children have under developed immune systems causing the diseases to severely attack their body (3).
Public health interventions have been in effect to prevent the spread of the disease. One particular intervention uses technology to promote HIV awareness (7-18). Short message service (SMS) is used to encourage mothers with HIV (7-18). Mothers are sent two messages daily, one reminding them to take their medication and the other with HIV facts (7-18). The messages mothers receive include lengthy information, in English. The intervention hopes to motivate mothers to continue treatment after doctor appointments and create awareness of mother-to-child HIV transmission (4). According to Cell-Life 80% of South African adults have access to a cell phone (15). Supporters of the intervention believe that the increase of technology will assist in decrease of mother-to-child HIV transmission (15). Being in a generation of technology, SMS messaging may be successful in providing facts and reminders to mothers (12); but the intervention lacks the awareness of the Social Cognitive Theory and the Health Belief Model (6, 8, 11).
The Social Cognitive Theory (SCT) incorporates personal and environmental factors (6). Direct communication from a peer role model with mothers suffering from HIV limits their exposure to personal information about the deadly disease (6, 9).  According to the Mother2Mother organization mothers are more likely to take action when they can relate to another suffering woman (9).  Education is limited to a number of South Africans (13). South Africans who are unable to obtain education are not given the opportunity to read the facts sent to them. Providing mothers with written facts assumes they are behaviorally capable of reading (11). Aside from education, women who are pregnant and suffering from HIV need additional motivation. The Cues to Action component in the Health Belief Model (HBM) believes that motivation is the foundation in getting individuals to take action (8). SMS messaging intervention assumes that mothers will be motivated by generic informational SMS messages. Without the understanding of social influence, individual capability and personal health the intervention was unsuccessful in engaging mothers. (6, 8, 11)
SMS Messaging Rejects Direct Communication
            SMS messaging hopes to promote individual change and decrease the spread of HIV (4, 10). However, SMS messaging limits face to face interaction. Strictly providing SMS messages to mothers isolates them from building a one-on-one or group relationship (9). Individuals receiving SMS messages are isolated from being part of the bigger picture.  Observational learning describes that behavioral changes are promoted by watching the actions and outcomes of others (6, 8). Sending SMS messages with reminders and facts limits direct exposure to the seriousness of HIV transmission. According to The National Cancer Institute, people do not solely learn from their own experiences (11), exposure to the experiences of mother’s in similar situations provides reassurance (6, 11).
The SMS messaging intervention negatively changes mother’s feelings about their parenting (18). The intervention fails to provide mothers with connection to mentors, health advocates or support groups (9). According to the Social Cognitive Theory mothers hesitate to make changes in their life when they are not exposed to credible role models (6, 11). The intervention’s rejection of direct communication and support pushes mothers to reject SMS messages and in turn the risk of HIV transmission continues (12).
Sending informational SMS messages does not promote interactive learning (18). Sending mother SMS messages about support group meeting time and locations can motivate them to want to meet someone in their position (9). In addition, including testimonials of mothers suffering from HIV can create a feeling of companionship for mothers. Providing support groups and testimonials allow mothers to connect and share stories and facts (9). Mothers will no longer feel alone or ashamed about their condition (9). Unfortunately, SMS messaging decreases the chances of mother’s ability to receive direct attention.
SMS Messaging Prediction of Behavioral Capability Fails
            Relying on SMS messages creates the assumption that all mothers can read. The Social Cognitive Theory describes Behavioral Capability as having the knowledge and skills to perform a behavior (6). Informational SMS messages were sent in a narrative format, in English (15). Not all South Africans read English, languages vary in different areas of South Africa (15). The language of the SMS messages sent to mothers failed to acknowledge a mother’s education levels. Unfortunately, 13.6% of South Africans cannot read (16). The intent of sending out reminders and SMS messages is to promote education and a successful health intervention (3-5, 7). However, the intervention will be unsuccessful if mothers cannot read (16). The hope to provide intervention through the usage of a cell phone will fail when mothers who cannot read ignore the SMS messages. As a result, mothers are not being educated on HIV and the benefits of taking action. If mothers who cannot read are unaware of the benefits they will not help themselves or their children. Mothers who do not take action have a higher risk of passing on HIV to their children (18).
            Behavioral Capability can be promoted by sending pictures for mothers who cannot read (6). Creating awareness through pictures can motivate mothers to get tested for HIV or continue to follow up with their appointments. According to, GBC Health, “without treatment, the risk of a mother transmitting HIV to her infant is estimated at 5-10% during pregnancy, 10-20% during labor/delivery, and 5-20% during breastfeeding” (7). Creating a picture for mother’s to see the effect of HIV on their body can decrease the chances of mother to child HIV transmission.
SMS Messaging Lacks Motivation
            HIV disease requires special attention (1-2). There is no clear correlation between the SMS messages received and the actions mother take (4, 15). Behavior is an outcome of cues to action (8); reminder SMS messages (4) and indirect contact lack words of motivation. Mothers can choose to ignore the SMS messages or prolong from taking their medication. On the other hand, there are mothers take the HIV facts as all the knowledge they need to know (9). Mothers begin missing their follow up appointments and stop attending support groups (9, 12). As more SMS messages are sent out, fewer mothers feel obligated to receive extra help.
            SMS messaging lacks interpersonal connection (6) and recognition of additional health concerns. SMS messages are being sent without the knowledge of a mother’s mental state. A mother’s emotional state can negatively impact her acknowledgement of her HIV SMS messages (14). The more distant the mother feels from her illness the less likely she is to help herself and her child (14). More than 1,000 mothers give birth to a baby with HIV each day (16). Pregnant women are at high risk for experiencing depression (14). SMS messages primarily focusing on a mother’s HIV can cause additional health risk including, suicidal thoughts, anxiety, stress (14). Aside from potentially having HIV additional prenatal health risk by a mother can affect a child’s development prenatal and postnatal (9-18). SMS messaging intervention limits interaction to personal motivational messages to promote effective lifestyle changes.
            The Social Cognitive Theory and Health Belief Model can be effective theories to further developing mother to child HIV transmission (6, 8, 11). However, the SMS messaging intervention focuses on HIV individuals as a group rather than individually.  SMS messages sent two times daily to mothers isolates mothers from connecting with others. Although messages include reminders to take medication and HIV facts (15), the information sent is not provided in their native language (18). Mothers who are uneducated are unable to benefit from SMS messages regardless of how valuable the information is. 
An effective cell phone SMS messaging approach would consider observational learning; which provides mothers with a support group to attend, or a personal contact that is aware of their condition and daily life (6). The language within the text can contribute to the overall outcome, providing specific, short facts in the language native to mothers is more likely to get response from mothers. On the other hand, mothers who are unable to read should be sent pictures. Pictures can open mother’s eyes to the effects of HIV. Eye opening message will motivate them to take their medication and follow up with their doctors’ appointments. Ultimately, SMS messages should build a connection with mothers. Mothers should feel motivated to get treated and protect their child. Messages should be personal by using family names and specifics about the mother’s condition depending on their stage. Overall, the intervention should address and include elements observational learning and behavioral capability from The Social Cognitive Theory as well as personal motivation to encourage mothers to act according to the Health Belief Model. Excluding the Social Cognitive Theory and the Health Belief Model will not influence mothers to treat their HIV, unfortunately leading to HIV transmission to their child.

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