Adoptability of digital payments for community health workers in peri-urban Uganda: A case study of Wakiso district

Veronica Kembabazi; Arnold Tigaiza; Charles Opio; Juliet Aweko; Mary Nakafeero; Fredrick Edward Makumbi; Michael Ediau; Elizabeth Ekirapa Kiracho; Andrew K. Tusubira; Peter Waiswa

doi:10.1371/journal.pone.0308322

Peer Review History

Original SubmissionMarch 26, 2024
27 May 2024 Decision Letter - Edison Arwanire Mworozi, Editor PONE-D-24-09580Adoptability of digital payments for Community Health Workers in peri-urban Uganda: a case study of Wakiso districtPLOS ONE Dear Dr. Kembabazi, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jul 11 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Review Reports Review Comments The research article is a very good paper which gives good and strong. The following are my comments; a. On the scope” why adoptability? Is that feasible with the country context? Why only CHWs? Why only NGO workers? What about the internet governance rule of Uganda? Why only among those doing campaign? Why peri-urban? Why only polio eradication Programme? b. The abstract lacks clarity c. The background can be stronger than this to convince the reader. d. The methods section is relatively good but • Inclusion criteria is weak to cover both study methods • Trustworthiness is not included • Sub themes were not explained • Case to variable ratio is great concern= for logistic regression • The reason foe selecting TAM should be explained more e. In the result and consequent sections � The detail character of the respondent is lacking E.g. age � The discussion is weak and weakly referenced � Some sections are missing E.g. Conflict of interest f. Inconsistency and grammar o IN the background “ to for” o Use of PIN Vs pin Regards, Reviewer #2: ### Review Comments to the Author General Comments: - The study presents valuable insights into the adoptability of digital payments among Community Health Workers (CHWs) in Wakiso district, Uganda. - The methodology appears sound, employing a mixed-methods approach to gather both quantitative and qualitative data, thereby providing a comprehensive understanding of the subject matter. - The findings highlight the significant role of perceived risk and trust in influencing the adoptability of digital payment modalities among CHWs. - The conclusion provides actionable recommendations for stakeholders to enhance the adoption of digital payment methods in the healthcare sector. Specific Comments: 1. Clarity and Organization: - The abstract succinctly summarizes the study objectives, methods, key findings, and conclusions. - The flow of information is logical and well-organized, guiding the reader through the background, methods, results, and conclusion seamlessly. 2. Methodological Rigor: - The use of the Technology Acceptance Model (TAM) framework adds rigor to the study by providing a theoretical basis for assessing the intention to use digital payment modalities. - Factor analysis and logistic regression strengthen the quantitative analysis, allowing for the identification of key determinants influencing adoptability. - Including qualitative data from Digital Payment Coordinators enriches the study by offering insights from stakeholders involved in facilitating digital payments. 3. Key Findings: - The finding that nearly all CHWs have previous experience with mobile money is noteworthy and underscores the familiarity of digital payment methods among the study population. - The identification of perceived risk and trust as critical factors influencing adoptability aligns with existing literature on technology acceptance and user behavior. - The qualitative findings regarding positive experiences with mobile money, despite some delays, provide valuable context for understanding CHWs' attitudes toward digital payments. 4. Recommendations: - The recommendations for collaborative efforts between payment providers and service operators to address payment delays and mitigate risks are actionable and align with the identified barriers to adoptability. - Suggesting strategies to enhance trust and alleviate perceived risks, such as transparent communication and risk management protocols, demonstrates a practical approach to promoting digital payment adoption. Overall Impression: - The study makes a significant contribution to the literature on digital payment adoption in the healthcare sector, particularly among CHWs in peri-urban settings. - The findings are relevant not only to stakeholders in Wakiso district but also to policymakers and practitioners seeking to leverage digital solutions to improve healthcare delivery and financial inclusion. - Addressing the review comments and incorporating any necessary revisions will enhance the clarity, rigor, and impact of the study. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0308322.r001
Revision 1
19 Jul 2024 Author Response Reviewer #1: Review Reports 1. The research article is a very good paper which gives good and strong. Response: Thank you 2. On the scope” why adoptability? Is that feasible with the country context? Why only CHWs? Why only NGO workers? What about the internet governance rule of Uganda? Why only among those doing campaign? Why peri-urban? Why only polio eradication Programme? Responses: “why adoptability?”: We chose to assess adoptability because the CHWs have used digital payments in previous community health activities and campaigns as well as in their day to day lives. We, therefore, wanted to see if they are willing to continue using digital payments for future community health projects. This is indicated in the last paragraph of the introduction section, line 105-110. “Is that feasible with the country context?”: Yes, adoptability of digital payments is feasible in Uganda. There are various forms of digital payments in Uganda, however, Mobile Money transfers run by telecommunication companies are the most feasible and readily available. These only requires one to have a phone (smart phone or not) and they can receive and send their money. We have connectivity of telecommunication services including mobile money agents across the country. Banks are also available across the country though not all the CHWs have accounts. “Why only CHWs?” Salaried cadres of the healthcare system in Uganda already receive payments digitally through bank transfers. CHWs, however, who are engaged and paid occasionally, often receive their money as cash. Payment with cash has been associated with several challenges as indicated in the introduction (line 101-104), such as time wasting as the wait for money at facilities since they’re always in large numbers, transportation of cash from the funders to the distribution centers is often a problem and sometimes results in loss of some funds, the accountability is a problem, and the money is usually not received in full amounts. Digital payments will address these problems in this population. In addition, CHWs are the lowest cadre in the health system, with lower literacy levels so, use of banks like for other cadres could be a challenge. “Why only NGO workers?” The study focused on CHWs who had ever been paid digitally and usually, payments are given by NGOs through their various community projects. Therefore, our inclusion criteria included having received payments digitally and the listed NGOs were some of the biggest funders of recent and ongoing community health projects. UNEPI coordinates government immunization programs in which CHWs are often engaged. “What about the internet governance rule of Uganda?” Digital payments systems mostly used in Uganda as well as the mobile money systems being recommended in the current study do not require internet. The issue of vulnerability to internet hacks and scams is therefore not significant. Besides that, CHWs as well as majority of the population in Uganda already use digital payments in their day to day lives. We wanted to see if these same services are adoptable in the health sector for payment of CHWs for their involvement in health activities. “Why only among those doing campaign?” CHWs are basically volunteers. Majority of their paid activities are community health campaigns such as immunization/vaccination. Therefore, at the time of sampling, majority or all of the CHWs who had received digital payments had been engaged in campaign activities (Line 67-73). “Why peri-urban?” Peri-urban because it gives a good representation of both the urban and the not so urban setting as a proxy for rural settings to show the adoptability in both settings. The findings on adoptability in peri-urban areas gives a starting point for the initiation of adoption of digital payments and scale up to other rural areas as guided by phone coverage. “Why only polio eradication Programme?” These were emphasized by WHO when recommending digital payments however these payment modalities can be used in other community health campaigns. Digital payments apply to other health campaigns besides polio eradication programmes. 3. The abstract lacks clarity Response: Thank you. The abstract was edited to provide more clarity. 4. The background can be stronger than this to convince the reader. Response: Thank you, we have made some additions to the background to make it stronger as guided. 5. The methods section is relatively good but; • Inclusion criteria is weak to cover both study methods Response: Thank you, this has been addressed. This survey was conducted among CHWs in Wakiso district who were carrying out community health activities in the district supported by various Implementing Organizations while In-depth interviewees were CHWs with varied experiences with digital payments and willing to share and Key informant interviewees were coordinators of CHWs and individuals who played key roles in management of digital payments for CHWs such as payment providers. See lines 135 – 138. 6. Trustworthiness is not included Response: Thank you. Trustworthiness is captured under “Trust” which is a main construct in the conceptual model for this study. Trust is explained in the methods, under the variables section as well as in the analysis plan and the results. 7. Sub themes were not explained Response: The sub-themes were added to the results section under each of the constructs (themes). See lines 294-368. 8. Case to variable ratio is great concern= for logistic regression Response: "The final model had 4 variables and a total of 150 observations which gave an average of 38 cases per variable. This satisfies the working assumption of 10-20 cases per variable in the model. (Ja, 2017) 9. The reason for selecting TAM should be explained more Response: The reasons for selecting TAM were explained in the study design between line 145 to 153. We have also added that the TAM could fit the local context. 10. In the result and consequent sections, the detail character of the respondent is lacking E.g. age Response: Thank you, details on age and gender have been added in the results section. See Table 3. 11. The discussion is weak and weakly referenced Response: Thank you, the comment has been addressed. 12. Some sections are missing E.g. Conflict of interest Response: Conflict of interest statement “The authors have declared that no competing interests exist,” was made in the submission portal as guided but the system. The PLOS One formatting guidelines indicate this, “Do not include funding or competing interests information in Acknowledgments” and there seems not to be provision for a section specifically for Conflict of interest in the same guidelines. 13. Inconsistency and grammar Response: Thank you, the manuscript has been reviewed by a professional language editor. 14. IN the background “ to for” Response: Thank you, this has been edited. 15. Use of PIN Vs pin Response: Thank you, this has been edited. Reviewer #2: ### Review Comments to the Author 1. The study presents valuable insights into the adoptability of digital payments among Community Health Workers (CHWs) in Wakiso district, Uganda. - The methodology appears sound, employing a mixed-methods approach to gather both quantitative and qualitative data, thereby providing a comprehensive understanding of the subject matter. - The findings highlight the significant role of perceived risk and trust in influencing the adoptability of digital payment modalities among CHWs. - The conclusion provides actionable recommendations for stakeholders to enhance the adoption of digital payment methods in the healthcare sector. Response: Thank you for appreciating 2. Clarity and Organization: - The abstract succinctly summarizes the study objectives, methods, key findings, and conclusions. - The flow of information is logical and well-organized, guiding the reader through the background, methods, results, and conclusion seamlessly. Response: Thank you for observing this 3. Methodological Rigor: - The use of the Technology Acceptance Model (TAM) framework adds rigor to the study by providing a theoretical basis for assessing the intention to use digital payment modalities. - Factor analysis and logistic regression strengthen the quantitative analysis, allowing for the identification of key determinants influencing adoptability. - Including qualitative data from Digital Payment Coordinators enriches the study by offering insights from stakeholders involved in facilitating digital payments. Response: Thank you for noticing this 4. Key Findings: - The finding that nearly all CHWs have previous experience with mobile money is noteworthy and underscores the familiarity of digital payment methods among the study population. - The identification of perceived risk and trust as critical factors influencing adoptability aligns with existing literature on technology acceptance and user behavior. - The qualitative findings regarding positive experiences with mobile money, despite some delays, provide valuable context for understanding CHWs' attitudes toward digital payments. Response: Thank you for appreciating 5. Recommendations: - The recommendations for collaborative efforts between payment providers and service operators to address payment delays and mitigate risks are actionable and align with the identified barriers to adoptability. - Suggesting strategies to enhance trust and alleviate perceived risks, such as transparent communication and risk management protocols, demonstrates a practical approach to promoting digital payment adoption. Response: Thank you for noticing this. 6. Overall Impression: - The study makes a significant contribution to the literature on digital payment adoption in the healthcare sector, particularly among CHWs in peri-urban settings. - The findings are relevant not only to stakeholders in Wakiso district but also to policymakers and practitioners seeking to leverage digital solutions to improve healthcare delivery and financial inclusion. - Addressing the review comments and incorporating any necessary revisions will enhance the clarity, rigor, and impact of the study. Response: Thank you for the observations References Ja, R. (2017). How many independent variables to include BEFORE running logistic regression? Retrieved from https://www.researchgate.net/post/How-many-independent-variables-to-include-BEFORE-running-logistic-regression/59bbc2ab96b7e4d751391ff0/citation/download Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0308322.r002
23 Jul 2024 Decision Letter - Edison Arwanire Mworozi, Editor Adoptability of digital payments for Community Health Workers in peri-urban Uganda: a case study of Wakiso district PONE-D-24-09580R1 Dear Kembabazi We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Edison Arwanire Mworozi, M.D Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0308322.r003
Formally Accepted
6 Aug 2024 Acceptance Letter - Edison Arwanire Mworozi, Editor PONE-D-24-09580R1 PLOS ONE Dear Dr. Kembabazi, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Professor Edison Arwanire Mworozi Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0308322.r004

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