Tobacco Cessation for People Living with HIV
Formative Research and Text Message Library Adaptation and Development
Link to Publication of Study Results
Text messaging-based interventions (TMIs) have demonstrated effectiveness in reducing tobacco use in many populations. However, such interventions have not been tailored to meet the complex medical and psychosocial factors confronting people living with HIV (PLWH) in sub-Saharan Africa (SSA). This study collected qualitative data required to adapt the SmokefreeTXT text-messaging library for people living with HIV (PLWH) who use tobacco in Uganda and Zambia.
Data was generated data from eight focus groups (N = 48) with PLWH tobacco users and four focus groups (N = 28) with healthcare providers recruited from HIV clinics across two regions in each country. Transcripts from these focus groups were coded thematically around cultural relevance, HIV-specific tobacco-use barriers, and message content preferences, offering a rich qualitative dataset on tobacco cessation attitudes and health-system context in sub-Saharan African PLWH populations.
A subset of participants then piloted the culturally adapted SMS intervention on their own phones for three weeks, providing usability and acceptability feedback (a smaller but valuable dataset for those studying digital health intervention uptake or SMS engagement metrics in low-resource settings).
The focus-group and usability data are specific to HIV clinic populations in Uganda and Zambia and may be particularly useful for comparative or cross-cultural research on tobacco cessation, HIV-comorbidity health communication, or mHealth adaptation methodologies in sub-Sharan Africa, though sample sizes are small and qualitative in nature rather than powered for statistical generalization.
Key Methods
Participants and recruitment
PLWH focus groups: Participants were initially recruited for focus groups at four clinics serving PLWH, two in Uganda (Arua, Moroto) and two in Zambia (Mongu, Chipata). Eligibility criteria were: (a) being age 18 or older; (b) being HIV positive and receiving ART services at one of the participating clinics at the time of the recruitment visit; and (c) using any type of tobacco in the past 30 days. At each clinic, an expert client was identified and enlisted to help contact eligible focus group participants. Due to the stigma of tobacco use by women in the geographic regions of the study, separate focus groups were conducted at each clinic for men (26 participants total; 6–8 per group) and women (22 participants total; 2–8 per group), resulting in a total of eight focus groups.
HSW focus groups: These participants were recruited across the participating health facilities for separate focus groups. One focus group was conducted at each of the four clinics serving PLWH just described (6–9 participants per group), resulting in four focus groups involving a total of 28 HSWs. Eligibility criteria for focus group participation were: (a) being age 18 or older; (b) working in a health services capacity at the clinic; and (c) having some knowledge of HIV and tobacco use.
PLWH usability testing
At a later point in time, after SmokefreeTXT had been adapted based on focus group feedback, participants were re-contacted to assess their interest in participating in the three-week usability testing of the short message service (SMS) program. To be eligible for this phase of the study, they needed to have their own phone and agree to be sent text messages. Of the 48 focus group participants, 14 (9 men, 5 women; mean age = 45.6) participated in the usability testing and returned for follow-up data collection three weeks later.
All participants provided informed consent and were compensated 10 USD for focus group participation, usability testing, and survey completion. All aspects of the study were approved by the institution’s internal review boards.
Data Analysis
Quantitative survey data: Means (standard deviations) and percentages were calculated for the quantitative survey items.
PLWH qualitative focus group data: Transcripts of the PLWH focus group discussions were reviewed by study personnel. These transcripts were then imported into Dedoose™. One member of the research team developed the first draft of the codebook, based initially on the focus group moderator guide, but expanded at the early stages of coding when additional relevant topics emerged. Specifically, themes focused on each topic area that was asked about during the discussion (e.g., dealing with cravings, motivation to quit, getting social support, benefits of quitting). Themes were also identified pertaining to barriers to quitting, the use of mobile phones to deliver the intervention, tobacco control interventions at the community level, and tobacco source and income. Finally, specific program suggestions had its own code in order to easily flag feedback for what could be added or changed related to the content or delivery of the program. Three researchers independently coded excerpts from one transcript, met to discuss the codes and resolve any coding discrepancies, and then finalized the codebook (e.g., refining definitions and inclusion/exclusion criteria for coding excerpts into specific themes). For each of the remaining seven transcripts, two coders independently coded the transcript, then met to discuss the codes and resolve any coding discrepancies, bringing all transcripts into 100% agreement.
HSW qualitative focus group data: Given the highly structured format of the HSW focus group moderator guide, we have listed responses under one of three main lines of inquiry from the moderator guide: (a) barriers that health service workers might encounter in helping PLWH quit using tobacco and strategies for addressing these barriers; (b) using SMS as a program to help PLWH quit tobacco and strategies for addressing SMS-related barriers; and (c) critical elements in tobacco cessation services for PLWH. Note that the HSW moderator guide included additional questions asked about the most effective tobacco cessation program to use with PLWH, the core or critical elements of this program, what changes or adaptations would need to be made to an existing program to make it as effective as possible for PLWH, and how to encourage PLWH to participate in a tobacco cessation program. We classified responses to these questions into one of the three main themes.