Acceptability of short message service reminders as the support tool for PrEP adherence among young women in Mukono district, Uganda

Adolescent girls and young women (AGYW) have a disproportionately high incidence of HIV compared to males of the same age in Uganda. AGYW are a priority sub-group for daily oral Pre-Exposure Prophylaxis (PrEP), but their adherence has consistently remained low. Short Message Service (SMS) reminders could improve adherence to PrEP in AGYW. However, there is a paucity of literature about the acceptability of SMS reminders among AGYW using PrEP. We assessed the level of acceptability of SMS reminders as a PrEP adherence support tool and the associated factors, among AGYW in Mukono district, Central Uganda. We consecutively enrolled AGYW using PrEP in Mukono district in a cross-sectional study. A structured pre-tested questionnaire was administered to participants by three trained research assistants. Data were analyzed in STATA 17.0; continuous variables were summarized using median and interquartile range (IQR) while categorical variables were summarized using frequencies and percentages. Acceptability of SMS was defined as willingness to accept SMS reminders to support PrEP adherence and was assessed using the seven constructs of the theoretical framework of acceptability. The relationship between the outcome and independent variables was assessed using a modified Poisson regression with robust standard errors. During 2022, 142 AGYW with median age 22 years (IQR; 18, 24) of whom 80.3% owned a personal mobile phone were assessed. SMS reminders were highly acceptable [90.9%, 95% Confidence Interval (CI) [84.9, 95.0]]. Rural residence (aPR: 0.92, 95% CI (0.84, 0.99)) and having belief that SMS cannot breach individual’s privacy (aPR: 1.40, 95% CI (1.07, 1.84)) were significantly associated with acceptability of SMS reminders. Having a personal mobile phone and acceptability of SMS reminders were high in this sub-population. SMS reminder can be leveraged to support AGYW to adhere to PrEP but should be designed in a way that maintains confidentiality, and supports AGYW living in rural settings. Methods The data set was collected through a reseacher administered questionnaire. The main dependent variable was acceptability of SMS reminders. This was measured using the seven constructs derived from the Theoretical Framework of Acceptability (TFA)(1). These include; affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy. A 5-point Likert item question per construct was used and each level of a Likert scale was given a weight ranging from one to five. The summated scores from the weights assigned to each response were computed. The obtained summated acceptability score was then dichotomized using the 50th percentile of the possible summated scores which ranges from 7 to 35 (the 50th percentile is 21). Therefore “Acceptability of SMS reminders" was defined as a value greater than 21. The independent variables were captured as described in the data dictionary attached Data analysis was performed in STATA version 17.0 (Texas, USA). At Univariate analysis, categorical variables were summarized using frequencies and percentages; and continous variables were summarized with median and inter-quartile range (IQR). The level of acceptability was calculated as a proportion of total participants that accepted the use of SMS reminders and its exact confidence interval (CI) was calculated. In the evaluation of factors associated with acceptability of SMS reminders, the primary outcome was the acceptability of SMS reminders as a PrEP adherence support tool recorded as a binary outcome (“Acceptable” versus “Not acceptable”). The relationship between the outcome and the independent variables was assessed using a modified Poisson regression model with robust standard errors. At bivariate analysis, the crude prevalence ratio (cPR) was computed together with the CI and P-value for each independent variable. The independent variables with a P value of less than 0.2 were included in the multivariate model. At multivariate analysis, Interaction was assessed using the chunk test (-2loglikelihood ratio test). Confounding was assessed and an independent variable was considered a confounder if they changed the magnitude of the adjusted prevalence ratio of another independent variable in the multivariate model by more than 10%. The adjusted prevalence ratio (aPR) was computed and reported together with the CI and P-value of each independent variable in the final model. statistical significancy was set at 0.05.在乌干达，青少年女性与青年女性（Adolescent Girls and Young Women，AGYW）的人类免疫缺陷病毒（Human Immunodeficiency Virus，HIV）感染率远高于同年龄段男性。AGYW是每日口服暴露前预防（Pre-Exposure Prophylaxis，PrEP）的重点亚组人群，但该人群的服药依从性始终处于较低水平。短消息服务（Short Message Service，SMS）提醒或可提升AGYW的PrEP服药依从性，但目前针对使用PrEP的AGYW对SMS提醒的接受度的相关研究仍较为匮乏。本研究针对乌干达中部穆科诺县的AGYW，评估了其将SMS提醒作为PrEP依从性支持工具的接受程度及相关影响因素。 本研究采用横断面研究设计，连续纳入穆科诺县内使用PrEP的AGYW。由3名经过培训的研究助理向受试者发放经过预试验的结构化问卷。数据分析采用STATA 17.0软件完成：连续变量以中位数和四分位数间距（Interquartile Range，IQR）进行汇总，分类变量以频数和百分比进行汇总。SMS提醒的接受度定义为愿意接受用于支持PrEP依从性的SMS提醒，采用接受度理论框架的7个维度进行评估。通过采用稳健标准误（robust standard errors）的改良泊松回归（modified Poisson regression）模型，分析结局变量与自变量之间的关联。 2022年期间，共纳入142名AGYW，中位年龄为22岁（四分位数间距：18~24），其中80.3%的受试者拥有个人移动电话。结果显示，SMS提醒的接受度较高[90.9%，95%置信区间（Confidence Interval，CI）：84.9~95.0]。农村居住（调整患病率比（adjusted Prevalence Ratio，aPR）：0.92，95%CI：0.84~0.99）与认为SMS不会侵犯个人隐私（aPR：1.40，95%CI：1.07~1.84）是与SMS提醒接受度显著相关的因素。 本研究人群中，拥有个人移动电话与对SMS提醒的接受度均处于较高水平。SMS提醒可被用于助力AGYW提升PrEP服药依从性，但相关设计需注重保护受试者隐私，并兼顾农村地区AGYW的使用需求。 方法 本数据集通过研究人员发放的问卷收集获得。 主要因变量为SMS提醒接受度，采用基于接受度理论框架（Theoretical Framework of Acceptability，TFA）的7个维度进行测量，分别为：情感态度、负担感知、感知有效性、伦理合理性、干预一致性、机会成本与自我效能感。每个维度采用1个5级李克特条目（5-point Likert item）进行评价，李克特量表的每个等级赋值1~5分，对所有条目赋值后的总分进行求和。所得总接受度评分以可能的总分区间（7~35）的第50百分位数（即21分）进行二分类，因此"SMS提醒接受度"被定义为总分大于21分。 自变量的收集方式详见所附的数据字典。 数据分析采用STATA 17.0软件（美国德克萨斯州）完成。单因素分析中，分类变量以频数和百分比汇总，连续变量以中位数和四分位数间距汇总。 接受度水平以接受SMS提醒的受试者占总人数的比例计算，并计算其精确置信区间（CI）。 在评估与SMS提醒接受度相关的影响因素时，主要结局变量为将SMS提醒作为PrEP依从性支持工具的接受度，以二分类形式记录（"可接受"与"不可接受"）。采用带有稳健标准误（robust standard errors）的改良泊松回归（modified Poisson regression）模型分析结局与自变量间的关联。单因素分析中，计算每个自变量的粗患病率比（crude Prevalence Ratio，cPR）及其95%CI与P值，将P<0.2的自变量纳入多因素模型。 多因素分析中，通过似然比检验（-2对数似然比检验）评估交互作用，通过调整其他自变量的调整患病率比（aPR）的幅度是否变化超过10%来判断是否存在混杂因素。最终模型中报告各自变量的调整患病率比（aPR）及其95%CI与P值，统计学显著性阈值设为0.05。