Feasibility of NepaDengue mobile application for dengue prevention and control: user and stakeholder perspectives in Nepal

Recruitment process

The pretesting phase of the mobile health application involved 228 university students purposefully selected from two campuses within ward no. 13 of Butwal Sub-Metropolitan City. Official approval was obtained from the respective campuses, which are known for being in a dengue hotspot area. This choice aimed to gather data from an environment with a higher risk of dengue transmission, enhancing the study’s relevance. Participants were selected based on their eligibility, which included being 18 years or older, possessing Android smartphones and having access to the Internet, either Wi-Fi or mobile data (online supplemental figure 4).

A sampling frame of 390 eligible students was prepared with the assistance of campus faculties, with 270 from campus A and 120 from campus B. Based on the proportionate sample size, 170 students from campus A and 90 students from campus B were approached to participate in the study. Among those approached, consent to participate was obtained from 159 students from campus A and 69 from campus B. The campus management team and students were involved directly in the intervention. We chose university students because university students are identified as early adopters of information, technology and knowledge who can quickly disseminate health education to peer groups and families. They are also among the groups that represent the community as a significant part and who have easy access to smartphones and are used to digital innovation, making them suitable for testing the feasibility of the application.

Informed consent, orientation and application download

Prior to participation, written informed consent was obtained from all eligible participants. An orientation session was conducted to demonstrate a comprehensive understanding of the study’s purpose and the features of the mobile health application. Eligible students were requested to download the mobile health application from the Google Play Store using a QR code or an APK file. The APK file was provided to facilitate easy download. Campus facilities, including Wi-Fi, were available for download, and a mobile data hotspot was provided to ensure accessibility. In addition, recharge cards and stationery items were provided to the participants as part of the compensation for their participation. Overall, guidance was provided by researchers on the application download process.

Stakeholder orientation

In parallel, an initial consultation meeting and orientation was conducted with key stakeholders involved in dengue management at central, provincial and local levels to establish a collaborative approach and gain insights from experts in the field. Stakeholders were invited to actively use the mobile health application during and after the orientation session. This hands-on experience allowed stakeholders to explore the application’s interface, functionalities and content.

Follow-up

Participants were instructed to engage actively with the application for a week. They were followed up after 1 week to assess their interaction with the application and gather feedback. This follow-up evaluated the acceptability score, overall user experience, facilitators and barriers to the mobile health application among the pretested cohort. Students’ perspective on acceptability was assessed through a self-administered questionnaire and focus group discussion, whereas organisational perspective on mobile health applications was assessed through key informant interviews with stakeholders. Additionally, a focus group discussion was done among FCHVs of Ward 3 of Butwal Sub-Metropolitan City (online supplemental figure 4). Throughout the follow-up process, participants were reminded of their voluntary participation, and the confidentiality of responses was assured. Participants were informed about the research objectives, and consent was obtained before taking recordings for qualitative data. Any concerns or questions raised by participants were addressed promptly (figure 3).

Study instrument

The TAM questionnaire was used to assess the acceptability of the application. The construct of TAM includes perceived usefulness, perceived ease of use, attitude and intention to use. The instrument used in this study comprised 21 items measured on a 5-point Likert scale. The points ranged from 1 to 5, given as 1 indicates strongly disagree, 2 indicates disagree, 3 indicates neutral, 4 indicates agree and 5 indicates strongly agree. Seven items for perceived usefulness and seven items for perceived ease of use were adapted originally from Davis,31 four items for attitude were adapted from Taylor and Todd33 and Park,34 three items for behavioural intention to use were adapted from Taylor and Todd,33 Agrawal and Prasad,35 Venkatesh.36 We assessed Cronbach alpha coefficients for adapted TAM that obtained 0.86. We used KII and FGD guidelines (online supplemental figure 5) to assess stakeholders’ and user perspectives, key facilitators and barriers to using the application.

Data analysis

For quantitative data, STATA V.14.0 was used for data analysis. Descriptive analysis was done for the sociodemographic information of participants. The mean score obtained in each construct of the Likert scale tool of the TAM questionnaire was calculated. A mean score >3 (out of 5) was considered a high mean rating score. A cut-off at >3 was set to simplify the interpretation, considering the score above this threshold indicates a positive response.

For qualitative data, thematic analysis (online supplemental figure 6) was conducted using NVivo V.12, where participants’ responses were categorised and subcategorised as per the frequency based on our predetermined variables based on the TAM conceptual framework questionnaire. A coding framework was developed, incorporating both predetermined and inductively derived codes. Responses were further analysed based on frequency to identify prominent themes and patterns.

Analysed quantitative and qualitative data were merged in the later phase to answer our research questions. Findings were interpreted in light of both quantitative metrics and qualitative narratives.

Perceived usefulness

The mobile app obtained a mean score rating >4 (out of 5), SD (0.51) for perceived usefulness (figure 4). Students found the application useful for obtaining health education on signs and symptoms, transmission, prevention, health news and hospital contacts. Additionally, stakeholders noted the app’s potential to assist in early planning and preparation. Stakeholders from EDCD highlighted the significance of a reminder notification feature aligned with the government campaign to clean breeding sites at least once a week and remind communities to adopt dengue preventive measures.

Request permission

I find this application useful because most of the information on Dengue is given there. The measures that should be taken when infected with Dengue are also included. If we are out of reach or alone and need a doctor’s consultation, we could contact you through the application.—P5, CCT

The one which I liked is the reminder alert. The Nepal government has recently made a policy to clean our surroundings and look after the water storage area and breeding sites. Do it regularly, if not possible, at least a week. And we are marketing that thing currently. So, those who have downloaded the application can get a notification about the time to clean their surroundings. Even if a person forgets, the application reminds them to conduct the activities, which is a positive thing.—DFP, EDCD

Perceived ease of use

The descriptive finding suggests a mean rating score of >3.8 (out of 5), SD (0.52) for perceived ease of use (figure 5). The finding implies that the application was clear and understandable and learning to use the application was not difficult. Both students and stakeholders found the application easy, informative and understandable. Stakeholders perceived that using both languages (English and Nepali) made the application easy to use. Observation and discussion among FCHVs in the community revealed that they could easily download and navigate through the application. However, one stakeholder stated that the ease of use depends on the exposure to the technology.

Request permission

Usually what happens is, at first, when you say mobile application, it is thought to be a complicated thing for the community level. There is a misconception that using Android mobile applications is complex for a community. Even I thought that way. But, when I went through this application, it is comfortable, easy to use, and get access to information easily.—Health Section In-charge, BMC

Attitude

The descriptive statistics reported a mean score rating of >4 (out of 5), SD (0.5) for the construct attitude (figure 6). The findings suggest that participants have a positive attitude towards using the application for dengue prevention and control. They perceive the application as innovative and relevant to the current dengue situation in Nepal.

Request permission

The application that is developed at the preliminary stage is very good. During the orientation, I appreciated it very much. …Otherwise, there are several other applications and software, but the application that you have developed is effective. Overall, the concept is perfect. – DFP, EDCD

Intention to use

The construct intention to change obtained a mean rating score of >3.5 (out of 5) and SD (0.65) (figure 7). Participants reported they would use the application in the future and would recommend others to use it. However, a few participants agreed they are not actively using the application as there are no dengue cases. However, they believe they would use it as needed in the future. The stakeholders at the district level believe that if there are no cases of dengue, people might not use the application.

Request permission

Right now, we are not actively using it because we do not feel the necessity. It might be because there are no cases of dengue or dengue outbreaks currently, but it is useful in the future and is a good app.—P4, BBC

Awareness raising

Stakeholders noted the low level of awareness regarding dengue among people and the misleading information circulated in the media. They stated that even though people know the term dengue at the community level, they do not know the transmission, symptoms and preventive measures. Using the application would address their major challenge to raise awareness and possibly be a reliable source to disseminate the correct information to the public.

… if we use this application, I think there will be a good level of awareness because people have access to smartphones. One thing is that those interested can get in-depth information about Dengue. Secondly, those who are infected, affected can use this application.—Dengue Expertise, VBDRTC

Search and destroy campaign

While the search-and-destroy campaign has been perceived as an effective strategy by stakeholders, it has been conducted as a part of a reactive response to the outbreak. It was stated that although the risk factors are present in the community all around the year, the community engagement for search and destroy is low. Stakeholders perceive this application would assist the campaign as there is direct communication with the community through which they can quickly locate the reported breeding sites.

Despite their perception of the application addressing their challenges, some stakeholders in the municipality believe the combination of printed materials and application would be appropriate in the community context.

Search and destroy have been found effective in the community. We can track people’s location for search and destroy campaigns. The app can make our work easier to conduct search and destroy. Through this app, we can orient/provide information about the dengue suspicion area for the representative of that particular community/location. We can inform them of their location in the app by telephone to the word representative, health workers, and FCHV. We can ask them to take action in those areas. It is good.—DFP, DHO, Rupandehi

Only using the conventional method will not work. We have to use the application and printed media as per the context of the population.—Health Section In-charge, BMC

Cost-effective means

The key informants reported that there is a limited budget allocated, resulting in increased expenditure on developing and updating IEC materials each year. At the community level, the challenge was to reach a wider population as people discarded pamphlets or printed sources. People are inclined towards the use of mobile phones. Stakeholders believe delivering information through an app would be convenient and accessible, making it a cost-effective choice for enhancing dengue awareness efforts.

Currently, we are using the conventional method for dengue awareness. If we use this application, it will be more cost-effective.—Dengue Expertise, VBDRTC

We feel we cannot reach a wider population other than this means because information through radio has been less effective these days. People do not use television much these days. So, if pamphlets are also given, people keep them in their pockets and throw them away. So, through the application, it is easy to reach the community in terms of cost. I think it will be cost-effective.—Health Section Staff, BMC

Illiteracy and availability of smartphone

Stakeholders highlighted that people have varying levels of digital literacy and smartphone usage.

Not everyone in the community is literate and uses smartphones, which creates a barrier to implementing the application. People without internet facilities and smartphones might not benefit from the application.

When this app is taken to the community level, the first thing we need to know is the smartphone-friendly population. How much is the coverage?—Dengue Expert, VBDRTC

Another challenge is not all people in the community use smartphones.—DFP, EDCD

Organisational challenges

At the central level, stakeholders anticipate challenges arising from the government’s inability to purchase the application outright and the need for ongoing updates, modifications and validation to align with the national programme. They express that the lack of ownership and control over the application’s development might restrict making necessary changes for nationwide implementation.

The application is already developed, and if you sell it, the government cannot purchase it. Moreover, if we need to update in between, bring new changes, or modify, then that would be a challenge.—DFP, EDCD

According to the municipality health section staff, they feel if the contents, IEC materials, in the application will have to be designed by themselves, they lack expertise. They would probably face technical issues with updating content. However, they are confident that an orientation or training would assist them.

If the contents have to be developed by us then, there could be challenges like designing IEC materials and putting them in the application. That expertise might not be with us. We could make it, but it might be compromised quality. In terms of updating contents, basic orientation and training would be enough for us.—Health Section Staff, BMC

Application promotion

Key informants emphasise that no matter how good the application is, it should be promoted widely for effective implementation and utilisation. Recognising that promoting the application during outbreaks might be challenging, they advocate for proactive dissemination of information beforehand. The promotion activities suggested are orientation targeting health workers representing health facilities in each administrative unit (Palika) and FCHVs, utilisation of diverse media outlets such as local FM radio stations, webpages, websites and social media platforms to amplify awareness, using official platforms, like the Ministry of Health and Population’s Viber group, which connects nearly a million individuals. The potential of media and digital platforms has been suggested as a means to reach a wider audience. However, stakeholders acknowledge that these promotion efforts would require time.

…when I dig further, why don't people use apps? Because we do not promote apps. The people who develop apps know about the application but not the users. We need to teach people in different places how to use the app, and promotion should be done widely.—Health Education Promotion Focal Person, NHEICC

Government ownership

For the effective implementation and public acceptance of the application, stakeholders emphasise government ownership. They stress the necessity of app ownership by the National Dengue Control Programme to allow it to make necessary modifications and officially endorse for nationwide dissemination.

…ultimately the application must be owned by the national government. Only after the government owns it can we market the application. …rather than just developing an application, if the Ministry of Health and Population and Program Division can adopt and request the public to use it, it will be great. If the national program owns that application and disseminates it widely, the public will own and accept the information.—DFP, EDCD

Collaborative approach

Rather than an individual effort, stakeholders suggest a collaborative approach for effective implementation and long-term sustainability of the application. At the central level, an agreement between the national programme team and the application designer team is recommended. Stakeholders stated that they are optimistic about adopting the application with some modifications. They emphasise the coordination between institutions, application developers, and EDCD for continued implementation and improvement of the application.

We must discuss and collaborate with the program division and technical expert. If there is collaboration, only we can easily use it as an effective tool. After the national program owns it, it wishes to take the property alone. How can we do it? If the approach is made institutionally, it is easier for the government to adopt it. If you approach individually, there might be issues in technicality regarding the backup, update, software, and server.—DFP, EDCD

Addition of dengue case reporting feature

As stated, the major challenge in the national dengue control programme has been in recording and reporting the number of cases. The existing Early Warning, Alert and Response System (EWARS) relies on hospitals to report cases, leaving gaps in assessing the overall case scenario in the community. Stakeholders believe incorporating a dengue self-case reporting feature would allow individuals to report the cases. They recognise that while not everyone may use the self-reporting feature, a significant portion could choose to do so. Moreover, even if only half of the diagnosed individuals report their cases through the app, it could significantly enhance understanding of the country’s dengue scenario.

If there is any sort of self-reporting mechanism from the app, it will be effective. Just like the IMU app for our COVID-19, if there is a name, a record of every patient. If the person is confirmed a dengue case, he/she can enter their details in the app; it will be more effective because there is no exact report of dengue cases with anyone… If only half of the diagnosed people report the case, we can know the scenario of our country.—DFP, PHD, Lumbini

Audio-visual aid

Both stakeholders and students suggested the integration of audio-visual aids like audio messages and linked videos to facilitate better understanding among the elderly and remote populations.

If we can make more pictorial messages, I think it will be good. For older people, it is good if we prepare audio messages.—Representative, EDCD

If there could be audio-visual information, it would be better. In the part of prevention, if we can include an audio message, the people in the rural part can easily understand.—P3, CCT

Update in line with the programme

According to the central level (EDCD), the emphasis was on the update of contents by recent changes regarding the alternative ways of vector control and atypical symptoms of dengue. Valuable insights from the National Health Research Council’s documentation of last year’s epidemic are also expected to provide valuable guidance for preparedness. Specifically, stakeholders recommend refining the health education contents of the application. The Nepali term for ‘dengue’ was expected to be consistently presented to ensure clarity and uniformity in spelling. Additionally, the suggestion to update the Nepalese name of the dengue mosquito to ‘Baage laamkhutte’ or ‘tiger mosquito’ was made to establish a relatable context for the user.

And recently, we have updated something in our program. We are also planning for alternative vector control methods like targeted indoor residual spray in some places and biological larvae sights. We are updating the complementary ways, too. Atypical classical symptoms and other risky symptoms have been observed, so NHRC is documenting the experiences of dengue patients from last year. That might also provide some insights. In addition to that, we need to update the program. Moreover, what we have planned is Dengue is one part, along with this, for other vector-borne diseases, we can focus on the vector control part of the application.—DFP, EDCD

Other suggestions

One key informant suggested incorporating a case alert system that would be instrumental in notifying and alerting people about the cases in their location, including suspected cases and trends.

Integration of additional vectorborne diseases could enhance the application’s usefulness and provide a comprehensive resource for public health awareness. Moreover, students highlight the offline availability of content, allowing users to access it even without internet connectivity. Likewise, when asked about what would make it attractive for them to use this application in the future, they responded that integrating educational games would engage them better.

The majority of information has been included in the application. In addition to the features, we can add an alert system based on location. Like the number of suspected cases in my area or particular location. Are cases rising? Is this the time to be aware? A type of warning for people. I think this is all… —Representative, EDCD

I think we can incorporate educational games so that we use them often.—P1, BBC