Determinants of Digitalized Antenatal Education Use among Pregnant Women Living with Human Immunodeficiency Virus in Nigeria

INTRODUCTION

METHODS

This is a cross-sectional analysis of the baseline data of a large intervention study conducted to evaluate the effectiveness of DAE on the prevention of mother-to-child transmission of HIV among PWLHIV.

RESULTS

Feasibility of DAE use among Participants

As presented in Table 2, a large proportion of the participants, 72 (77.4%), reported that they were not familiar with DAE at all. However, 84 (90.3%) of the women believed that it would be highly effective, despite the low levels of familiarity and participation. In addition, the willingness to engage with DAE is notably high, as 78 (83.9%) of the participants indicated that, although they had not participated in DAE, they would consider doing so [Table 2].

Table 2: Feasibility of DAE use among participants.

Variables	Frequency (%)
Level of familiarity with DAE
Not familiar at all	72 (77.4)
Not very familiar	9 (9.7)
Somewhat familiar	8 (8.6)
Very familiar	4 (4.3)
Participation in DAE
No, but I would consider it	78 (83.9)
Yes occasionally	6 (6.5)
Yes regularly	4 (4.3)
Accessibility to DAE
Not accessible at all	1 (1.1)
Somewhat accessible	17 (18.3)
Very accessible	75 (80.6)
Effectiveness of DAE
Highly effective	84 (90.3)
Not very effective	2 (2.2)
Somewhat effective	7 (7.5)
How DAE can address psychosocial needs
Moderately well	13 (14)
Not very well	3 (3.2)
Very well	77 (82.8)

DAE: Digitalized antenatal education

Overall, the feasibility of DAE use is high in 83 (89%) of the participants [Figure 1].

Figure 1:

Feasibility of digitalized antenatal education use among participants.

Acceptability of DAE use among the Participants

The results presented in Table 3 show that the majority of the participants, 73 (78.5%), indicated that DAE addresses their specific needs very well, and 77 (82.8%) of them reported being very comfortable with using DAE. Furthermore, 73 (78.5%) reported being very likely to recommend DAE when asked to indicate their willingness to recommend DAE use. In addition, the reliability of the information provided through DAE was rated as highly reliable by 82 (88.2%) of the pregnant women, and 85 (91.4%) of them rated the DAE content as being very culturally sensitive [Table 3].

Table 3: Acceptability of DAE use among the participants.

Acceptability	Frequency (%)
DAE addresses specific needs
Moderately well	12 (12.9)
Not very well	8 (8.6)
Very well	73 (78.5)
Comfortable discussing sensitive topics using DAE
Not sure	1 (1.1)
Not very comfortable	4 (4.3)
Somewhat comfortable	9 (9.7)
Very comfortable	77 (82.8)
Recommendation of DAE to others
Not likely at all	2 (2.2)
Not very likely	8 (8.6)
Somewhat likely	10 (10.8)
Very likely	73 (78.5)
Reliability of information provided in DAE
Highly reliable	82 (88.2)
Moderately reliable	11 (11.8)
Cultural sensitivity of DAE
Not very culturally sensitive	1 (1.1)
Somewhat culturally sensitive	7 (7.5)
Very culturally sensitive	85 (91.4)
Continue using DAE resources
Not likely at all	2 (2.2)
Not very likely	5 (5.4)
Somewhat likely	6 (6.5)
Very likely	80 (86)
Satisfaction with the quality of DAE
Not satisfied at all	1 (1.1)
Not very satisfied	1 (1.1)
Somewhat satisfied	12 (12.9)
Very satisfied	79 (84.9)

DAE: Digitalized antenatal education

Overall, the level of acceptability of DAE use was high in 73 (78.5%) of PWLHIV [Figure 2].

Figure 2:

Acceptability of digitalized antenatal education among participants.

DISCUSSION

The study used a descriptive cross-sectional research design to assess the use of DAE and identified determinants of DAE use among PWLHIV.

The majority of the participants are within the reproductive age^[10], who affirmed that women in this age range show increased interest in digital health platforms, particularly when such tools are tailored to their time constraints and lifestyle. Most of the women were married. Olajubu et al.^[11] highlighted that spousal involvement positively influences the uptake of antenatal services, including digital interventions. Religious affiliation was almost evenly split between Christianity and Islam. Rahman et al.^[12] emphasized that religious beliefs play a key role in shaping health behaviors, and therefore, DAE content must be inclusive and respectful of diverse religious values to ensure wider acceptability. The population was largely Yoruba. The delivery of health education in local languages and with culturally familiar symbols has been shown to improve understanding and retention, as demonstrated by Musiimenta et al.^[13] in their study on mHealth in East Africa. With a large proportion of respondents engaged in the informal sector as traders and artisans, the DAE program must be designed for flexibility. A study by Van Pelt et al.^[14] noted that mHealth interventions offering asynchronous access and voice-based prompts were highly effective among informal sector workers. In terms of education, the majority of participants had completed secondary education, while some had tertiary education. According to Fan et al.,^[15] women with at least secondary education are more likely to engage with digital health tools effectively. The study also revealed that the majority of the respondents were not in their first pregnancy, and nearly half had two or more previous deliveries. Multiparous women, as observed by Arnold et al.,^[10] often seek updated information and reassurance through digital platforms, especially when previous pregnancy experiences were complicated. Their previous experiences and knowledge gained during previous antenatal care could influence their perception of DAE.

The feasibility of DAE among PWLHIV appears promising, despite significant gaps in awareness. A large proportion of participants reported being completely unfamiliar with DAE. This low level of familiarity aligns with previous research by Kebede et al.,^[16] who found that limited digital health awareness is a major barrier to adoption, particularly among women in lower-resource settings. Nonetheless, the same study emphasized that when digital health tools are introduced effectively, they tend to gain rapid acceptance. Remarkably, despite this unfamiliarity, a strong willingness to adopt DAE was evident. A substantial number of participants stated that while they had not yet engaged in DAE, they would consider participating in it in the future. This finding reflects the concept of “latent receptiveness” discussed by Bakibinga et al.,^[17] which suggests that many pregnant women, especially those living with HIV, are open to innovative educational models if these are perceived to be beneficial and non-judgmental. In terms of accessibility, the data present an encouraging scenario: most of the respondents reported that DAE is very accessible. This is consistent with findings by Osei and Boateng,^[18] who noted that mobile device penetration and internet availability in urban and semi-urban African communities are creating fertile ground for the use of digital maternal health tools. When evaluating perceived effectiveness, the majority of the participants believed DAE to be highly effective. Fan et al.^[15] highlight that perceived utility is a strong predictor of adoption, often more influential than prior use. This suggests that the benefits of DAE – such as convenience, confidentiality, and personalized content – are well recognized, even if theoretical at this stage. For PWLHIV, such features are particularly crucial, as they allow access to care without the stigma often associated with physical health facility visits.^[13] In addition, a striking number of participants felt that DAE would address their psychosocial needs. This highlights DAE’s potential to serve as more than just an information delivery platform. According to a study by Sinha et al.,^[19] digital tools that include components for mental health, peer support, and emotional reassurance are highly valued among HIV-positive mothers.

The acceptability of DAE among PWLHIV is notably high, as evidenced by multiple positive indicators. A substantial majority of participants affirmed that DAE effectively addresses their specific maternal and health-related needs. This aligns with the findings of Akintunde et al.,^[20] who emphasized that tailored digital health content, especially when customized to reflect the lived experiences of vulnerable groups like women living with HIV, can significantly improve perceived relevance and user satisfaction. When it comes to discussing sensitive topics such as HIV status, stigma, sexual health, or mental well-being, most of the women indicated that they felt very comfortable using DAE platforms. According to Musiimenta et al.,^[13] digital platforms provide a safe environment for women to explore personal health issues without fear of judgment or disclosure, thereby fostering greater openness and engagement. In terms of advocacy, the willingness to recommend DAE to others was high, with most stating they were very likely to do so. A similar pattern was found in a study by Bakibinga et al.,^[17] which showed that recommendation plays a key role in scaling digital health solutions among African women, especially when peer approval reinforces trust and credibility. The reliability of information provided through DAE was endorsed by the majority of the respondents, who rated it as highly reliable. Sinha et al.,^[19] argue that the trustworthiness of content, backed by validation from health professionals, is a strong determinant of the acceptability of digital interventions. For PWLHIV, accurate and reliable content also reduces confusion and misinformation, which are common barriers to health-seeking behaviors. Cultural relevance is another area where DAE appears to perform exceptionally well. A striking number of participants described the content as very culturally sensitive. This finding supports the conclusions of Osei and Boateng^[18] who asserted that culturally tailored interventions significantly enhance user engagement and acceptability, especially in settings where traditional beliefs heavily influence maternal behaviors. Regarding continued usage, most of the participants reported that they were very likely to keep using DAE resources. According to Fan et al.,^[15] digital health platforms that are intuitive, relevant, and adaptable are more likely to retain users long-term. For women managing both pregnancy and HIV, ongoing access to support tools can provide stability and confidence throughout the perinatal period. Finally, satisfaction with the overall quality of DAE was impressively high, with most of the women reporting being very satisfied. Kebede et al.^[16] emphasize that satisfaction plays a pivotal role in digital health success, as it directly influences future participation, adherence to advice, and the likelihood of recommending the service to others.

The adoption of DAE among PWLHIV is shaped by a complex interplay of facilitators and barriers. One of the strongest facilitators identified was support from healthcare providers, with almost all of the respondents acknowledging this as a key motivator. This finding is consistent with Nguyen et al.,^[21] who emphasized that endorsement by healthcare professionals enhances the credibility and perceived safety of digital health tools, particularly for vulnerable populations. Similarly, perceived relevance and cultural sensitivity emerged as important facilitators. According to Osei and Boateng,^[18] interventions that align with users’ lived experiences and cultural beliefs are more likely to be accepted and sustained. Digital literacy was identified as a significant facilitator, with most of the respondents indicating they had the skills to interact with digital platforms. This finding corresponds with Musiimenta et al.,^[13] who noted that digital competence is a foundational requirement for the successful adoption of mHealth interventions. Other important facilitators include internet access and time availability. Fan et al.^[15] argued that access to reliable internet and autonomy over 1’s time are essential for the feasibility of any digital health initiative.

Despite these enabling factors, several barriers persist. Device availability was cited as a constraint by almost half of the respondents. This underscores a significant infrastructural gap, confirmed by Amoakoh-Coleman et al.^[22] who reported that device unavailability is one of the biggest obstacles to mHealth adoption in sub-Saharan Africa. This calls for effective offiine interventions for childbearing women. Thus, offiine interventions and a community-based device sharing model are highly recommended for the implementation of DAE among pregnant women. Another major obstacle was the quality of audio and visual content, which almost all of the participants identified as a challenge. This finding aligns with Gurman et al.,^[23] who stressed that poorly designed user interfaces and low-quality content reduce user satisfaction and trust in digital interventions. Lack of social support networks was also a significant barrier, with the majority of the participants noting it as a limitation. Social isolation is a known issue for women living with HIV, and Sinha et al.^[19] argue that the absence of peer or family support can negatively affect maternal healthcare utilization. Privacy concerns were reported by almost one-third of the participants, highlighting a critical issue for women managing a stigmatized condition like HIV. According to Kebede et al.,^[16] fear of unintended disclosure is a common deterrent to using digital health services among HIV-positive populations. Although cost considerations were a barrier for only a few of the respondents, affordability remains a relevant factor, especially in low-income households. This supports findings by Bakibinga et al.,^[17] who found that digital health tools offer long-term savings on transportation and clinic visits. Partner support was reported as a facilitator by most of the participants, but also presented a barrier for a few of them. This highlights the gendered dynamics influencing digital health adoption. Akinfaderin-Agarau et al.^[6] noted that male partner approval can significantly shape women’s participation in health programs. Additional facilitators identified in this study include the trustworthiness of information, language preference, and flexibility of access. These findings mirror Schnall et al.^[24] who emphasized that trust, linguistic appropriateness, and on-demand availability are fundamental features that enhance the utility and credibility of digital maternal health tools.

Conclusively, PWLHIV have positive dispositions to DAE use as displayed by their perceived effectiveness of DAE, even though many of them do not have access to it, and are not familiar with it. They are optimistic about using DAE. Therefore, policymakers and stakeholders in maternal health and HIV prevention should promote facilitators of DAE use among pregnant women and plan interventions that could mitigate the identified barriers to improve digital health in low-resource settings like Nigeria. Furthermore, program implementers might need to consider offiine interventions to be able to reach women who do not have access to internet-enabling devices, and those who have restricted or no internet access. In addition, future research could investigate how digital literacy could be improved among pregnant women, as well as the effectiveness of offiine interventions that could promote PMTCT.

CONCLUSION AND GLOBAL IMPLICATIONS

The use of DAE is feasible and acceptable among PWLHIV in Nigeria. However, effective interventions such as training programs for digital literacy (especially for childbearing women), subsidies for smartphones, and integrating DAE into routine HIV and maternal health care to promote its facilitators are highly recommended. In addition, the content of such interventions should be culturally sensitive to reduce stigmatization among vulnerable populations, such as PWLHIV. A lot of efforts still need to be put in place if PWLHIV in low-resource settings like Nigeria will meet the global standards in the utilization of digital health.