Characteristics of the participants
A total of 35 women between ages 18 and 44 years (median age=24 years), participated in the study. All the participants were married women and 89% (n=31) were farmers. Most of the participants (n=33) had some level of education. Most of the participants spoke two languages (Tiv and English). Majority of the participants (n=31) made ₦20,000 (twenty thousand Nigerian Naira) or less per month. (Table 1)
Table 1
Characteristics of female participants of focus group discussions in Benue State, Nigeria
Characteristic (N=35) | Frequency |
LGA | |
Buruku | 3 |
Gwer West | 11 |
Konshisha | 9 |
Tarka | 12 |
Number of children | |
None | 6 |
1 or 2 | 16 |
>2 | 12 |
Missing | 1 |
Level of education | |
None | 2 |
Completed primary | 7 |
Completed junior secondary | 10 |
Completed senior secondary | 11 |
Some post-secondary | 3 |
Completed post-secondary | 2 |
Main language spoken | |
English | 21 |
Tiv | 14 |
Income | |
₦0 – ₦20,000 | 31 |
₦20,001 - ₦50,000 | 3 |
>₦50,000 | 1 |
All the participants reported that they had received their mHealth cards at least a month prior to the discussions about its use. All the women reported that they received consent from their spouses before participating in the FGDs. About half of the participants reported that they had used the smartcard, which was scanned at the hospital with a phone to display their information. The reasons for not using the smartcard include not knowing how to use the card, not knowing the card can be used at other health facilities, forgetting to go to the hospital with the cards, not having had an appointment since given the smartcard, and not having gone to the clinic personally. The participants’ responses are summarized in Table 2.
Table 2
PEN-3 table of analysis showing findings in each domain
Cultural Empowerment |
Relationship/ Expectation | Domains | Positive | Existential | Negative |
Perceptions | -Perceived the card to be beneficial. -Understood the purpose of the card. | -Not sure of the scope of information in the card. -Not certain why the card is free. -Not sure if the smart card program will apply to their babies. | -Thoughts that the card gives access to free medical screening. -Did not understand why they were selected. -Afraid they received the card because of an illness. |
Enablers | -The benefits that they received by using the card: card reduced the time spent at the facility, ease of utilizing services available at the clinic, reduced cost by not repeating laboratory investigations that have results stored on the cards. -Demand for use of the card by healthcare worker. -Availability of LGA Research Assistants and healthcare workers to give information and clarification. -Card can be used in any of the participating facilities. -The positive experience from the “Baby Shower” program | -No cultural belief against the use of the cards. -Not having had a hospital appointment since given the card. | -Cost of treatment at the health facilities. -Use of the card by someone other than client. -Not knowing how to use the card. -Not knowing the card can be used at other participating health facilities. -Forgetting to go to the hospital with the cards. |
Nurturers | -Approval from husbands -Support from household members | -Family accepts use of orthodox medicine/healthcare | -Negative ideas from families and neighbours |
Perceptions (attitudes towards mHealth card and its use)
Positive perceptions
Most of the participants understood the purpose of the card. Almost all the participants perceived the card to be important for their healthcare and likened it to an ATM (Automated Teller Machine) card that contained all their biodata and investigation results. They believed the card was made for their health benefit as it reduced their healthcare cost as they did not have to repeat some laboratory investigations. All participants who had used the card were happy that they did not have to spend money to repeat laboratory investigations or have additional needle pricks. Some of them were happy that it could be used even when they are away from home. Most of the women acknowledged that the mHealth card made it faster and easier for the healthcare workers at the hospitals to retrieve their laboratory results stored on their cards instead of searching for hospital folders, resulting in shorter waiting times. Most of them reported that the card helped them know more about their health status and helped the healthcare worker to know their diagnosis, hence, reducing the time spent at the facility as the users were asked fewer questions at the health facilities.
“I like using the card at the hospital, it saves the work of checking files or folders. It also produces my results faster.” (Participant 19)
When describing the benefits associated with using the card, some of the participants expressed that they liked the ability to use the mHealth card in different health facilities. This would allow for easy transfer of information from one health facility to another. In this regard, majority of the participants viewed the mHealth card to be compatible and usable in various health facilities in their community.
“I feel if I go to a different hospital, I can still use the card. So, I like it. Also, the card has helped me know more about myself as regards my health…It contains my health information, so I like it.” (Participant 15)
Negative perceptions
Some of the participants did not understand why they were selected to receive the cards and were concerned at the first instance. Some participants were initially afraid that they received the card because of an illness. One participant felt it could be due to issues with her pregnancy while another felt she may have a health challenge; however, they got convinced that presenting the card at the hospital will make their treatment easier. Some other participants did not have accurate information about the cards. Some were not certain why the card was free while others were not sure if the program will apply to their babies. Some felt they will incur additional costs by taking the card to the hospital while some others felt the card will give them access to free medical services. Another group of participants reported that they did not think they could use the mHealth cards in other health facilities serving pregnant women. Most of the participants were not sure if the card captures every data about their health or only the laboratory investigations done during the “Baby Shower” program. The “Baby Shower” program was a health intervention delivered in churches to celebrate pregnancy and deliver integrated onsite health screening for pregnant women.[40]
“We were many that participated in the baby-shower program why is the cards given to only few of us? I became worried when I noticed this”. (Participant 8)
Enablers (factors that represent barriers to or facilitators of mHealth card use)
Positive enablers
When describing the facilitators that contributed to their use of the cards, participants who had used the mHealth cards stated that the healthcare worker’s request for the card in the facilities they visited made them use the cards. Most participants reported they had been asked for the card at the health facility. The fact that the cards could be used in any of the participating facilities also enabled more women to use the cards. Again, the availability of LGA Research Assistants and healthcare workers to give information and clarification aided the use of the cards. Participants discussed how receiving assistance in the form of technical support and response to questions from the program facilitators, the nurses and even the doctors encouraged their use of the mHealth cards. One participant shared that the on-going discussions about the card with program facilitators were important in supporting her use of the card. When describing how to encourage participants to use the card, it was noted that the women should be provided with more information on the card.
“Yes, the facility workers were always asking me about the card whenever I went for ANC visits. At the facility, they asked me to always bring the card, they always scan it and return to me.” (Participant 2a)
“Whenever I have questions about the card, I asked the program facilitator, the nurse or doctor. They give me more information concerning the card.” (Participant 5b)
The positive experience from the “Baby Shower” program was another enabler. Some participants perceived the mHealth card to be beneficial by linking it to the incentives received during the “Baby Shower” program. They liked that the card was free and came with some form of support. They were thankful to and encouraged the sponsors of the “Baby Shower” program.
“I liked the gifts given to me during the baby shower so when the card was given, I knew it was another good thing so when I was invited over for the interview, I didn't hesitate.” (Participant 18)
The participants were unanimous in their response that their cultural beliefs will not hinder their proper use of the cards.
Negative enablers
When describing factors that acted as barriers to using the cards, the costs associated with seeking treatment was cited as the most prevalent barrier. Some participants believed that although the cards allowed them to have various tests for free, subsequent costs associated with treatment were among their reasons for not using the cards. One participant shared the following:
“Tests were done and we have our results, just that there has been no money at the moment to go to the hospital for treatment.” (Participant 4b)
Other barriers reported by the women include inadequate information on the use of the card and unauthorized use of the card. A few women reported that poor knowledge of how to use the card and not knowing that the card could be used at other participating health facilities prevented them from using the cards. One participant reported an unauthorized use of the card by her husband at a health facility. This unauthorised use was a barrier to her further use of the card.
Nurturers (The role of support systems with using the m-health card)
Positive nurturers
The influence of family and neighbours on the acceptability and use of the mHealth cards were highlighted. All the participants reported that they received consent and support from their spouses to use the card. Most participants also reported that they received support from members of their households. When participants were asked to describe key individuals who supported their use of the mHealth cards, participants said that receiving support from their family members, particularly their spouse increased their use of the cards.
“I only showed the card to my husband and he accepted that I keep and make use of the card.” (Participant 7a)
“When I showed it to my household, I did not get any negative comments or rejection of the card.” (Participant 4a)
Negative nurturers
A few of the participants reported that they were discouraged from using the cards by friends, neighbours and relatives. A few of the women were mocked that the card will not have a lasting impact given that similar projects have failed in the past. Others were told they received the card because they were sick.
“I was told by people around me that the card is given to those with HIV/AIDS only and this prompted me to take it to the hospital for verification which I found out it was not true of what people said.” (Participant 14)
“Some people that I showed the card said negative things about the card, that the project will not achieve it aims and objectives since other organisations had come with similar projects that never stayed to the end”. (Participant 5a)