Phone Access Research Articles

Digital revolution and the gender divide: factors affecting mobile phone use in India

ABSTRACT As the world digitises, being able to access and use a mobile phone is important in order to be able to participate fully in day-to-day life, accessing digital services and online information. While mobile phone handsets and cheap data plans are now ubiquitous in India, women’s access to and use of mobile phones is significantly more limited than that of men. The availability of the technology is therefore not the only factor affecting women’s access and use of mobile phones. This paper proposes a novel framework operating at three levels – individual, family and community levels, to understand the factors that affect women’s access to and use of mobile phones, and provides a snapshot of mobile phone access and use of low-income women in India based on 60 structured interviews across six states. We find that women’s mobile phone use is often constrained, based on personal factors – confidence to use a phone or adequate digital literacy; family-level factors – permission to use the phone, monitoring of phone use and community-level factors – socio-cultural norms around appropriate type and place of use. This paper contributes to a significant gap in the literature on digitisation and women’s access and use of mobile phones in India. It highlights that while the digital revolution holds great promise, the use of mobile phones is often constrained for women.

Determinants of rural women economic empowerment: the Case of Bahir Dar Zuria Woreda in Amhara Region, Ethiopia

The issue of women's empowerment has been a topic of ongoing discussion in developing countries, considering the complex socio-demographic and cultural factors at play. Women tend to face disadvantages compared to men across various human development indicators. Therefore, it is crucial to thoroughly examine the different factors that influence women's economic empowerment within the specific context of Ethiopia. This study examines the factors that contribute to the economic empowerment of women in rural areas of Bahir Dar Zuria Woreda in the Amhara Region of Ethiopia. The research employed multi-stage probability sampling techniques to achieve its objectives, resulting in a sample of 382 rural women randomly selected from seven selected kebeles. Descriptive statistics and binary logistic regression were used to analyze the collected data. The study found that more than half of the women achieved a medium level of economic empowerment. The results revealed that age, educational status, income contribution, and ownership of property positively influenced rural women's economic empowerment. In addition, opening a savings account, information access, mobile phone accessibility, and membership of women's associations positively and significantly affect women's economic empowerment in the study area. Conversely, marital status, hours spent on unpaid work, and early age at marriage negatively.

Balancing digital literacy and children’s wellbeing: A call to action

Balancing digital literacy and children’s wellbeing: A call to action Given children’s increased exposure to digital technologies, Leen d’Haenens from the University of Leuven discusses findings from a research project called ySKILLS, which aimed to enhance the positive impact of the digital environment on children’s wellbeing. As technology rapidly advances, the debate over when children should have mobile phones intensifies among parents, researchers, and experts. While concerns about the risks of mobile phones for children are prevalent, the potential benefits are often overlooked. Parents are increasingly using platforms like WhatsApp and Telegram to discuss these issues, and in the US, tech giants face legal action for allegedly exploiting children’s vulnerabilities. Some parents liken delaying mobile phone access to regulating alcohol and cars until age 18, but this comparison may not be apt.

Political Economy of Agriculture and Food Policy in Africa

This article reviews the literature on the political economy of agricultural and food policy in sub-Saharan Africa. In doing so, it first presents a conceptual framework highlighting that agricultural and food policy decisions are contingent on the intersection between governance structures, the preferences and pressures from societal interest groups, and international dynamics. The interrelations among these three factors are then examined across several different sets of policy instruments that have been the focus of traditional political economy research in the region: trade, tax, and marketing policies; public investments and regulations; input and food subsidies; and cross-cutting policies for value chain development. Recognizing several broader demographic, technology, and governance transitions in the region, the article also highlights key areas for future analysis that examine the role of cities in food policy, the possibilities presented by expanded mobile phone and Internet access, and the efficacy of new public administration modalities for policy implementation.

Parent-Child Communication Dynamics in Muhammadiyah Pagesangan Orphanage

Background: Effective communication is essential for nurturing children's moral development, particularly in orphanages. Specific Background: This qualitative study investigates communication dynamics between four caregivers and 19 children at the Muhammadiyah Pagesangan Orphanage in Surabaya. Knowledge Gap: Limited research exists on communication methods used in orphanages, especially for children from diverse socioeconomic backgrounds. Aims: The study aims to analyze communication patterns in moral guidance within the orphanage. Results: Findings indicate that children employ both primary and secondary communication methods to connect with distant parents, facing challenges such as limited phone access and socio-economic barriers. Novelty: This research highlights unique communication challenges in orphanages and proposes that effective communication fosters a nurturing environment. Implications: By promoting a loving communication atmosphere, caregivers can enhance children's emotional well-being and moral development, suggesting that communication is crucial for effective caregiving practices in orphanage settings. Highlights : Communication Patterns: Emphasizes the need for understanding how caregivers interact with children. Challenges: Identifies barriers faced by children in maintaining contact with parents. Nurturing Environment: Highlights the role of effective communication in promoting emotional well-being. Keywords: communication, orphanage, moral development, caregivers, qualitative research

Effect of Mobile Phone Access on Non-Farming Self- Employment and Income Among Female-Headed Households in Tanzania

Effect of Mobile Phone Access on Non-Farming Self- Employment and Income Among Female-Headed Households in Tanzania

Household information and communication technology usage and post-harvest losses in Nigeria

PurposePost-harvest losses are becoming a huge issue globally and predominantly severe in developing countries. Food losses decrease farm income by 15% for about 480m small-scale farming households. With technology adoption, particularly, Information and Communication Technology (ICT) usage, minimising post-harvest losses will be more effective, because of its ability to build households’ human development by bridging the information gap.Design/methodology/approachThis study empirically examines the impact of ICT usage on post-harvest losses in Nigeria, utilising Wave 4 (2018/2019) of the Living Standards Measurement Studies (LSMS), Integrated Survey on Agriculture (ISA). The study engages the Logit regression and Propensity Score Matching (PSM) to analyse the data.FindingsThe findings show that post-harvest losses constitute about 38% of household agricultural production. In addition, it shows that the influence of ICT is statistically significant and positive in reducing post-harvest losses.Research limitations/implicationsIt implies that access to mobile phones and the Internet by households helps in developing their human capital through information access, for example, by linking them to the market and enhancing value chain participation. In addition, the implication is that mobile phone and Internet access contribute 1.87% and 2.68%, respectively, to reducing post-harvest losses. The findings suggest that there is a need for the government to improve support mechanisms for ICT usage among farming households.Social implicationsThe study contributes to the society by examining how the well-being of farmers can be improved upon in order to increase their productivity.Originality/valueThe study on the contribution of ICT to post-harvest losses is relatively sparse in the extant literature. Therefore, this study is among the very few to empirically examine the impact of different ICT indicators, using the LSMS-ISA (2019) data and engaging propensity matching, while focusing on the household heads.

Consumers Accessing Their Mobile Phone in an Acute Inpatient Mental Health Unit: Experiences of Consumers and Staff

Mobile phones are an essential means for remaining connected, yet many acute inpatient mental health units restrict consumer access to their mobile phones due to safety concerns. The ubiquitous nature of mobile phones makes this approach seemingly incongruent with contemporary mental health practice. One Local Health District in Australia evaluated the implementation of a process that provided mental health consumers access to their mobile phones while in hospital. This study used a mixed methods design to explore the views of consumers and nurses, both before and after implementation. Participants were asked about their perceptions of the importance of mobile phone access to people in acute units, and their views about any perceived (pre) and actual (post) issues, challenges or benefits associated with the change in practice. Survey responses showed significant differences across group on all measures, with consumers more likely to rate the importance and frequency of mobile phone use higher, while also significantly more likely to rate potential issues lower. Issues associated with consumer phone access were rated lower in the post surveys. Descriptive content analysis of qualitative data identified differences in the level of concern between staff and consumers about consumers having access to their phone before implementation. Views about the therapeutic benefits and level of concern also changed post implementation. The need to have a clear process for implementation and governance was identified by both groups. The findings support consumers having access to their phone during admissions to acute mental health units.

A survey on digital device engagement, digital stress, and coping strategies among college students in the Philippines

ABSTRACT This study surveyed 384 Filipino college students on their digital device engagement, digital stress, and coping strategies. Findings revealed that students were heavily reliant on digital devices. They used digital devices for at least 15 minutes daily upon waking and before sleeping. They encountered significant digital stress, particularly from social media, online learning platforms, games, and video streaming. Facebook emerged as the most stress-inducing platform. While students felt a strong need for constant phone access, they seldom feared missing out on experiences. Students reported self-distraction and positive reframing as their coping strategies. Importantly, the study identified a positive correlation between digital device engagement and digital stress manifestation, emphasizing the adverse impact of extensive device use on stress levels among college students. The insights in this study may guide policymakers in developing policies that foster responsible and healthy technology use among youth, shaping the environment and resources available to them.

Attitudes of female market vendors of reproductive age towards use of mobile phones and access to family planning self-care interventions in Northern Uganda: a cross-sectional study

BackgroundMobile phones are potential digital technologies for accessing family planning self-care interventions. However, their utilization could be possible if women of reproductive age have positive attitudes towards the use of this technology for healthcare purposes. This study aimed to examine the relationship between attitudes towards the use of mobile phones and access to family planning self-care interventions among female market vendors of reproductive age in northern Uganda.MethodsA cross-sectional survey design was used. Two hundred and five randomly selected female vendors from the Gulu city main market participated. A structured researcher-administered questionnaire was used to collect the data. Descriptive statistics and standard multiple regression were performed, and the data were analysed using SPSS software version 15.ResultsOf the 205 participants, 112 (54.6%) reported using smartphones, and 147 (71.7%) were aware of family planning self-care interventions. Participants had moderate attitudes towards access to family planning self-care interventions (mean = 3.18), positive attitudes towards ease of use (mean = 3.31) and usefulness of mobile phones (mean = 3.30), strong positive attitudes towards privacy (mean = 4.04), and skills associated with using mobile phones (mean = 4.04). Furthermore, significant positive relationships existed between ease of use (p value = 0.000), skills (p value = 0.001), privacy (p value = 0.002) and access to family planning self-care interventions. There was, however, an insignificant positive relationship between mobile phone usefulness and access to family planning self-care interventions (p value = 0.189).ConclusionsParticipants’ positive attitudes towards the use of mobile phones could lead to access to FP self-care interventions, although uncertainty about the usefulness of the use of mobile phones for accessing FP self-care interventions exists. It is therefore important for healthcare practitioners, health development partners and the government to encourage and integrate the use of mHealth into regular FP self-care services and promotional activities while targeting underserved communities in Uganda.

Student attitudes towards smartphone use in a pre-service teacher tech course

In contemporary classrooms, characterized by students who are digital natives with a firm reliance on mobile phones, integrating these devices into educational activities presents an opportunity to enhance learning experiences and increase engagement. This qualitative case study investigates undergraduate pre-service teachers’ perceptions of using smartphones for learning activities in a Teacher Education Program (T.E.P.) technology course at a 4-year institution in the U.S. The researchers sought to examine how the use of smartphones influenced the students’ learning experiences. Understanding students' experiences can inform the development of strategies to enhance technology-integrated lessons and foster improved learning environments. The findings indicated that students had positive experiences with using smartphones in class. They found the devices to help enhance online learning security and were reliable, versatile, and affordable compared to other forms of technology. The ability of the devices to download and accommodate a variety of educational materials was also a valuable attribute for the students. However, challenges associated with unrestricted phone access in the classroom, including the risk of addiction, distraction, decreased engagement, and concerns regarding academic integrity, were reported. As smartphones become integral to our learning environment, educators should establish policies promoting responsible usage to optimize students' learning potential rather than imposing bans. The researchers propose that institutions invest in innovative software solutions to manage smartphone usage proactively. This approach enables students to enhance their focus and productivity during crucial learning moments while mitigating distractions posed by mobile phones.

Feasibility, acceptability and equity of a mobile intervention for Upscaling Participatory Action and Videos for Agriculture and Nutrition (m-UPAVAN) in rural Odisha, India.

Addressing undernutrition requires strategies that remove barriers to health for all. We adapted an intervention from the 'UPAVAN' trial to a mobile intervention (m-UPAVAN) during the COVID-19 pandemic in rural Odisha, India. In UPAVAN, women's groups viewed and discussed participatory videos on nutrition-specific and nutrition-sensitive agricultural (NSA) topics. In m-UPAVAN, weekly videos and audios on the same topics were disseminated via WhatsApp and an interactive voice response system. We assessed feasibility, acceptability, and equity of m-UPAVAN using a convergent parallel mixed-methods design. m-UPAVAN ran from Mar-Sept 2021 in 133 UPAVAN villages. In Feb-Mar 2021, we invited 1000 mothers of children aged 0-23 months to participate in a sociodemographic phone survey. Of those, we randomly sampled 200 mothers each month for five months for phone surveys to monitor progress against targets. Feasibility targets were met if >70% received videos/audios and >50% watched/listened at least once. Acceptability targets were met if >75% of those watching/listening liked the videos/audios and <20% opted out of the intervention. We investigated mothers' experiences of the intervention, including preferences for m-UPAVAN versus UPAVAN, using in-person, semi-structured interviews (n = 38). Of the 810 mothers we reached, 666 provided monitoring data at least once. Among these mothers, feasibility and acceptability targets were achieved. m-UPAVAN engaged whole families, which facilitated family-level discussions around promoted practices. Women valued the ability to access m-UPAVAN content on demand. This advantage did not apply to many mothers with limited phone access. Mothers highlighted that the UPAVAN interventions' in-person participatory approaches and longer videos were more conducive to learning and inclusive, and that mobile approaches provide important complementarity. We conclude that mobile NSA interventions are feasible and acceptable, can engage families, and reinforce learning. However, in-person participatory approaches remain essential for improving equity of NSA interventions. Investments are needed in developing and testing hybrid NSA interventions.

Investigating the healthcare-seeking behaviors of mobile phone users to improve cervical cancer screening in rural Uganda.

Cervical cancer is the leading cause of cancer in low- and middle-income countries, despite being preventable. Uganda, which lacks an effective screening program, has one of the highest global cervical cancer incidence rates. Mobile health (mHealth) technology has the potential to improve healthcare-seeking behaviors and access. The present study describes the connection between mobile phone access and healthcare-seeking behaviors in rural Uganda. Women were eligible for this cross-sectional study if they had no prior screening or treatment for cervical cancer in the past 5 years, were aged 30 to 49 years old, and were residents of the South Busoga Forest reserve. Survey data was analyzed using descriptive statistics and chi-square tests. Of the 1434 participants included in the analysis, 91.4% reported having access to a mobile phone. Most respondents were aged 30-40 years, had a partner, had ≤primary education, and were farmers. Participants with mobile phone access were significantly more likely to report attending a healthcare outreach visit (access = 87.3%, no access = 72.6%, P < 0.001) or visiting a health center (access = 96.9%, no access = 93.5%, P < 0.001). Participants in both groups had largely positive attitudes around and good knowledge of cervical cancer screening. While attendance to healthcare services was high amongst participants, those with mobile phone access were more likely to seek healthcare services. Further inquiry into this association between mobile phone access and healthcare-seeking behavior is needed to optimize the improvements to cervical cancer screening when implementing interventions such as mHealth technology.

Factors Associated With Lack of Long-Term Follow-Up Data After Global Cardiac Surgery Missions.

Background: Humanitarian medical missions attempt to lessen the burden of limited access to cardiac surgery in low- and middle-income countries. While organizations express difficulties obtaining follow-up information, there is currently little evidence to support the various assumptions for lack of data. This study examines the factors influencing long-term patient follow-ups on repeated short-term cardiac surgery missions across nine countries. Methods: A retrospective analysis of CardioStart International's database (RedCap) was conducted to investigate demographic, socioeconomic, and surgical factors associated with follow-ups. Results: A total of 550 pediatric (50%) and adult (50%) cardiac surgery patients displayed a follow-up rate of 14.7%, with no significant difference between populations (P = 1). Mean follow-up time was 1.5 years postoperative. Countries were highly variable, with Dominican Republic and Vietnam showing follow-up rates of 30.4% and 43.2%, respectively, while Brazil, Nepal, and Tanzania had no follow-ups (P < 0.0001). The 11 surrogate factors for socioeconomic status, including home amenities and technology access, were predominantly insignificant, with the exception of phone access showing an unexpectedly decreased follow-up rate (11.6%, P = 0.006). Surgical intervention was a significant factor (P = 0.009). No adult cardiac surgery trends were noted; however, congenital cases demonstrated increased follow-ups in patients with higher Risk Adjusted Congenital Heart Surgery scores, with ventricular septal defects (32.5%) exceeding atrial septal defects (7.3%). Conclusions: Follow-ups correlate with mission factors, including location and types of intervention, more so than previously assumed socioeconomic and technological factors. Thus, certain missions may require more allocation of resources and adapted organizational policies to overcome site-specific barriers to follow-up.

Centering healthcare workers in digital health design: Usability and acceptability of two-way texting to improve retention in antiretroviral therapy in a public HIV clinic in Lilongwe, Malawi.

New initiates on antiretroviral therapy (ART) are at high risk of treatment discontinuation, putting their health at risk. In low- and middle-income countries, like Malawi, appropriate digital health applications (apps) must fit into local clinic, connectivity and resource constraints. We describe the human centered design (HCD) and development process of an open-source, hybrid, two-way texting (2wT) system to improve ART retention. We detail the critical role of diverse healthcare workers (HCWs) in the HCD process to inform app usability, create buy-in, and ensure appropriate optimization for the local context. We optimized 2wT usability and acceptability over three HCD phases: 1) informal feedback sessions with diverse 2wT stakeholders, 2) a small pilot, and 3) key informant interviews. Phase one included four sessions with diverse HCWs, including "expert ART clients", clinical, technical, supervisory, and evaluation teams to inform 2wT design. In phase 2, a small pilot with 50 participating ART clients aimed to inform implementation improvement. Phase three included interviews with ten HCWs to deepen understanding of 2wT acceptability and usability, documenting strengths and weaknesses to inform optimization. Multi-phase feedback sessions with HCWs helped refine 2wT language and message timing for both weekly and tailored client-specific visit reminders. The pilot led to improvements in educational materials to guide client responses and ease interaction with HCWs. In interviews, the HCWs appreciated the HCD co-creation process, suggested ways to increase access for low-literacy clients or those without consistent phone access, and felt integrating 2wT with other eHealth platforms would improve scalability. Inclusion of HCWs across phases of HCD design, adaption, and optimization increased 2wT usability and acceptability among HCWs in this setting. Engaging HCWs into 2wT co-ownership from inception appears successful in co-creation of an app that will meet HCW needs, and therefore, enhance support for 2wT clients to attend visits and remain in care.

"Technology has allowed us to do a lot more but it's not necessarily the panacea for everybody": Family physician perspectives on virtual care during the COVID-19 pandemic and beyond.

Early in the COVID-19 pandemic, Canadian primary care practices rapidly adapted to provide care virtually. Most family physicians lacked prior training or expertise with virtual care. In the absence of formal guidance, they made individual decisions about in-person versus remote care based on clinical judgement, their longitudinal relationships with patients, and personal risk assessments. Our objective was to explore Canadian family physicians' perspectives on the strengths and limitations of virtual care implementation for their patient populations during the COVID-19 pandemic and implications for the integration of virtual care into broader primary care practice. We conducted semi-structured qualitative interviews with family physicians working in four Canadian jurisdictions (Vancouver Coastal health region, British Columbia; Southwestern Ontario; the province of Nova Scotia; and Eastern Health region, Newfoundland and Labrador). We analyzed interview data using a structured applied thematic approach. We interviewed 68 family physicians and identified four distinct themes during our analysis related to experiences with and perspectives on virtual care: (1) changes in access to primary care; (2) quality and efficacy of care provided virtually; (3) patient and provider comfort with virtual modalities; and (4) necessary supports for virtual care moving forward. The move to virtual care enhanced access to care for select patients and was helpful for family physicians to better manage their panels. However, virtual care also created access challenges for some patients (e.g., people who are underhoused or living in areas without good phone or internet access) and for some types of care (e.g., care that required access to medical devices). Family physicians are optimistic about the ongoing integration of virtual care into broader primary care delivery, but guidance, regulations, and infrastructure investments are needed to ensure equitable access and to maximize quality of care.

The Dilemma of Unlawful Digital Interventions and Their Impacts on the Rohingya Community During the Covid-19 Pandemic

This study explores the impact of unlawful digital interventions on the Rohingya community in Bangladesh during the COVID-19 pandemic. The Rohingya refugees, who have faced severe persecution in Myanmar, found themselves in refugee camps in Bangladesh, where they initially had limited access to technology and the internet due to legal restrictions. However, by using the Ethnoscape and Mediascape of globalization theory devised by Arjun Appadurai, the study aims to understand the unlawful digital interventions in the camps during the Covid-19 pandemic. This unauthorized access to digital platforms played a crucial role in raising awareness among the Rohingya population during the COVID-19 pandemic. The study conducted in three Rohingya camps employed qualitative methods, including focus group discussions, in-depth interviews, and observations, to understand the significance of unauthorized digital platform usage, particularly during the COVID-19 pandemic. Adolescent males and females with smartphones acquired knowledge about COVID-19 through social media platforms like Facebook, Imo, WhatsApp, and YouTube, leading to intergenerational debates within the community, as the elderly relied more on television broadcasts. The study highlighted the critical role of social media in shaping the community's knowledge and perceptions of the pandemic and to take precautionary measures, though they encountered misleading content. While digital platforms facilitated information sharing and financial transactions, gendered restrictions on smartphone usage were evident, reflecting patriarchal control over young girls' mobile phone access.

Smartphone use decreases trustworthiness of strangers

Trust is crucial for social, economic, and political relationships. Evidence shows the importance of trust in distinct areas, from the day-to-day forming of personal relations to the stability of democracies. In this paper, we ask how new technologies that compete for our attention affect the formation of trust between strangers. To that end, we study how smartphone use affects interactions with, and subsequent trust in, strangers. In our experiment, we had participants wait in groups of six for approximately 20 minutes, allowing them to interact as they wished. In one treatment, participants could use their smartphones during the wait time, while in the other they did not have access to their phones. We then randomly paired participants within each group to play a trust game and answer a brief survey. As predicted, we find that limiting phone access resulted in higher levels of trustworthiness.

Investigation of the Impact of Wellinks on the Quality of Life and Clinical Outcomes in Patients With Chronic Obstructive Pulmonary Disease: Interventional Research Study.

Wellinks is a remote disease management solution that provides novel chronic obstructive pulmonary disease (COPD) care delivery. This study evaluated the satisfaction, engagement, and clinical outcomes of Wellinks participants. This study also investigated the cadence of health coaching for patients with COPD. A 24-week interventional study was conducted by Wellinks and the COPD Foundation in 2022. Adults with COPD were recruited by the COPD Foundation in the United States and determined to be eligible if they had phone and internet access, owned a smartphone, and were not currently participating in pulmonary rehabilitation. All study participants provided written informed consent. The Wellinks solution included remote health coaching, pulmonary rehabilitation, and group education; participants were provided the Wellinks app and smart spirometry and pulse oximetry devices. Participants were offered 6 coaching sessions in the first 12 weeks. For the second 12-week period, participants either reduced frequency or discontinued coaching; all other components of the Wellinks solution remained unchanged. The COPD Self-Efficacy Scale, Modified Medical Research Council dyspnea scale, pulmonary function, pulse oximetry, and patient-reported healthcare resource utilization were the clinical outcome measures. Nonclinical outcomes included engagement and satisfaction with Wellinks and net promoter score. In total, 141 adults consented and completed Wellinks onboarding; 84.4% (n=119) of whom remained engaged throughout the 24-week study. Participants had a mean age of 70 (SD 7.8; range 48-88) years, and 55.7% (n=78) were female. Most participants (n=119, 84.4%) completed all 6 coaching sessions during the first 12-week period. Compliance with spirometer and pulse oximeter use was 82.3% and 89.4%, respectively, at week 1 but waned over the study period to 8.5% and 9.2%, respectively, at the end of the study. Participants indicated a high degree of satisfaction with Wellinks, with 95.5% (n=85) and 91% (n=81) of participants indicating that they agreed or strongly agreed that the educational content and health coaching, respectively, were valuable. At the end of the study, the net promoter score was +64 and +55 in the coaching continuation and discontinuation arms, respectively. A significant improvement from baseline to end of the study was observed in the COPD Self-Efficacy Scale total score (P<.001) and domain scores (P<.001 for each domain). In total, 35.1% (n=27) of participants improved by at least 1 category of change on the 5-point Modified Medical Research Council dyspnea scale from baseline to week 24. This study confirmed the feasibility of using a remote model of care delivery to support people living with COPD. The insights gained in this study have allowed for further refinement and personalization of the Wellinks care model. Findings related to the combined use of technology and personal care delivery should be considered by others developing remote disease management tools. ClinicalTrials.gov NCT05259280; https://clinicaltrials.gov/ct2/show/NCT05259280.

Implementing ecological momentary assessments to measure violence and adolescent HIV transmission risk: Lessons from Johannesburg, South Africa.

Ecological Momentary Assessment (EMA) is an important methodology to understand risky behaviour and holds promise for HIV research. EMA is still novel in sub-Saharan Africa. We describe challenges and lessons learned on a novel study implementing mobile phone EMAs with adolescent boys in South Africa. The Tsamaisano study was a longitudinal study from 2020-2023 to recruit adolescent boys aged 15-19 years; including those without HIV and those perinatally infected and living with HIV. Participants were prompted to complete 52 weekly mobile phone survey on emotional state, exposure to and perpetration of violence, and sexual risk behaviour. Surveys were delivered using a random algorithm to choose the day. We incorporated mechanisms to assess challenges and optimize survey completion: weekly team meetings with youth representation and real-time data monitoring. Additionally, 20 frequent vs infrequent survey submitters participated in qualitative interviews about barriers and recommendations. Real-time monitoring indicated low (defined as <50%) survey completion in the first months of study implementation. To ensure that both the adolescent participant and their caregiver understood the commitment required for successful EMA, we created and implemented a guided discussion around mobile phone access during the enrolment visit. We identified a need for increased and ongoing technical support; addressed by creating technical guides, implementing a standard two-week check-in call after enrolment, adding an automated request button for call-back assistance, creating a WhatsApp messaging stream, and reaching out to all participants failing to submit two sequential surveys. Entry-level smartphones, including those initially distributed by the study, did not have capacity for certain updates and had to be replaced with more expensive models. Participants struggled with randomly allocated survey days; completion improved with set completion days and targeted reminder messages. Together, these steps improved survey completion from 40% in December 2020 to 65% in April 2022. We describe key lessons learned to inform future study designs with mobile phone EMAs, drawing on our experience implementing such among adolescent boys, including persons living with HIV, in a low-and-middle income setting. The key lessons learned through the Tsamaisano study are important to inform future study designs with EMA utilizing mobile phone, electronic data collection among adolescent boys in low-and-middle-income settings.