Digital Adherence Technologies and Mobile Money Incentives for Management of Tuberculosis Medication Among People Living With Tuberculosis: Mixed Methods Formative Study

Abstract

Background Although there is an increasing use of digital adherence technologies (DATs), such as real-time monitors and SMS reminders in tuberculosis medication adherence, suboptimal patient engagement with various DATs has been reported. Additionally, financial constraints can limit DAT’s utility. The perceived usefulness and the design mechanisms of DATs linked to mobile money financial incentives for tuberculosis medication management remain unclear. Objective The aim of this study is to describe the perceived usefulness and design mechanisms for a DAT intervention called My Mobile Wallet, which is composed of real-time adherence monitors, SMS reminders, and mobile money incentives to support tuberculosis medication adherence in a low-income setting. Methods This study used mixed methods approaches among persons with tuberculosis recruited from the Tuberculosis Clinic in the Mbarara Regional Referral Hospital. We purposively sampled 21 persons with tuberculosis aged 18 years and older, who owned cell phones and were able to use SMS text messaging interventions. We also enrolled 9 participants who used DATs in our previous study. We used focus group discussions with the 30 participants to solicit perceptions about the initial version of the My Mobile Wallet intervention, and then iteratively refined subsequent versions of the intervention following a user-centered design approach until the beta version of the intervention that suited their needs was developed. Surveys eliciting information about participants’ cell phone use and perceptions of the intervention were also administered. Content analysis was used to inductively analyze qualitative data to derive categories describing the perceived usefulness of the intervention, concerns, and design mechanisms. Stata (version 13; StataCorp) was used to analyze survey data. Results Participants expressed the perceived usefulness of the My Mobile Wallet intervention in terms of being reminded to take medication, supported with transport to the clinic, and money to meet other tuberculosis medication–related costs, all of which were perceived to imply care, which could create a sense of connectedness to health care workers. This could consequently cause participants to develop a self-perceived need to prove their commitment to adherence to health care workers who care for them, thereby motivating medication adherence. For fear of unintended tuberculosis status disclosure, 20 (67%) participants suggested using SMS language that is confidential—not easily related to tuberculosis. To reduce the possibilities of using the money for other competing demands, 25 (83%) participants preferred sending the money 1-2 days before the appointment to limit the time lag between receiving the money and visiting the clinic. Conclusions DATs complemented with mobile money financial incentives could potentially provide acceptable approaches to remind, support, and motivate patients to adhere to taking their tuberculosis medication. Trial Registration ClinicalTrials.gov NCT05656287; https://clinicaltrials.gov/ct2/show/NCT05656287

Appraising perception, accessibility and uptake of DAT among patients with TB

“…This is supported by another study that reported financial constraints as a notable limitation and proposed a potential role for financial incentives. 34 …”

Acceptability of a Digital Adherence Tool Among Patients With Tuberculosis and Tuberculosis Care Providers in Kilimanjaro Region, Tanzania: Mixed Methods Study

“…A study done in South Africa reported that the acceptability of DAT was highly associated with its ease of use among patients [ 12 ]. The real-time medication monitoring reports and feedback on adherence helped patients understand their health conditions and led to improved patient and health care provider relationships [ 12 , 24 , 25 ]. In addition, it led to improved care practice and behavior change among TB care providers.…”

Digital Adherence Technologies Linked to Mobile Money Incentives for Medication Adherence Among People Living With Tuberculosis: Mixed Methods Feasibility and Acceptability Study

“…Details of the My Mobile Wallet intervention are described elsewhere [ 13 ]. Briefly, as shown in Figure 2 , the intervention is composed of the following 3 components: a real-time medication monitor (Wisepill evriMED1000) to monitor medication adherence by sending signals when opened (the monitor records a date-and-time stamp as a proxy for taking medication, and it has an option to set an alarm sound to remind patients to take their medication); SMS text message reminders sent to users’ mobile phones to remind them to take their medication as prescribed (reminders are sent daily for 2 months, after which they are triggered as needed by missed or delayed doses); and the WiseCash app, which uses a tailored mobile money platform for sending financial incentives for transport to the clinic and motivating medication adherence.…”

“…The use of mobile money technology (money sent, received, or saved on mobile phones) is a promising tool for delivering health-related cash transfers; for instance, mobile money enabled pregnant women to save for maternal health care in Kenya [ 11 ], while a progressive incentive scheme to reward private physicians and community health care workers enhanced identification and referral of suspected tuberculosis cases and treatment tracking in Pakistan [ 12 ]. The use of mobile money transfers to incentivize patients living with tuberculosis to take their drugs may potentially improve their adherence to medication [ 13 ]. However, the use of mobile money services in the context of health care is still in its infancy, and the limited research in this area reports mixed results [ 14 ].…”

“…The financial incentives are meant to motivate participants to take their medication as well as enable them to attend their clinic appointments for pill refills. The intervention was developed through user-centered approaches [ 15 ], and we previously published formative qualitative findings indicating the anticipated benefits and challenges of using the intervention for tuberculosis medication adherence in rural Uganda [ 13 ]. In brief, participants reported that the intervention could remind them to take their medication as well as support, and motivate tuberculosis medication adherence.…”