Explaining Differences in the Acceptability of 99DOTS, a Cell Phone–Based Strategy for Monitoring Adherence to Tuberculosis Medications: Qualitative Study of Patients and Health Care Providers (Preprint)

Abstract

BACKGROUND 99DOTS is a cellphone-based strategy for monitoring tuberculosis (TB) medication adherence that has been rolled out to more than 150,000 patients in India’s public health sector. A considerable proportion of patients stop using this monitoring approach during TB therapy. OBJECTIVE We aimed to understand reasons for variability in the acceptance and use of 99DOTS by TB patients and healthcare providers (HCPs). METHODS We conducted qualitative interviews with individuals taking TB therapy in the government program in Chennai and Vellore (HIV co-infected patients) and Mumbai (HIV un-infected patients) across intensive and continuation treatment phases. We also conducted interviews with HCPs with various roles in TB care, all of whom were involved in implementing 99DOTS. Interviews were transcribed, coded using a deductive approach, and analyzed with Dedoose 8.0.35 software. Study findings were interpreted using the Unified Theory of Acceptance and Use of Technology (UTAUT), which highlights four constructs associated with technology acceptance: performance expectancy, effort expectancy, social influences, and facilitating conditions. RESULTS We conducted 62 interviews with TB patients, of whom 30 (48%) were HIV co-infected, and 31 interviews with HCPs. Acceptance of 99DOTS by patients was variable. Greater patient acceptance was related to perceptions of improved patient-HCP relationships from increased phone communication, TB pill-taking habit formation due to SMS reminders, and reduced need to visit health facilities (performance expectancy); improved family involvement in TB care (social influences); and from 99DOTS leading HCPs to engage positively in patients’ care through increased outreach (facilitating conditions). Lower patient acceptance was related to perceptions of poorer patient-HCP relationships from less face-to-face contact (performance expectancy); problems with cellphone access, literacy, cellular signal, or technology fatigue (effort expectancy); high TB- and HIV-related stigma within the family or community (social influences); and poor counseling in 99DOTS by HCPs or perceptions that HCPs were not acting upon adherence data (facilitating conditions). Acceptance of 99DOTS by HCPs was generally high and related to perceptions that the 99DOTS patient adherence dashboard and patient-related SMS alerts improve quality of care, efficiency of care, and the patient-HCP relationship (performance expectancy); that the dashboard is easy to use (effort expectancy); and that 99DOTS leads to better coordination among HCPs (social influences). However, HCPs described suboptimal facilitating conditions during 99DOTS rollout, including inadequate training of HCPs, unequal changes in HCP workload, and shortages of 99DOTS medication envelopes. CONCLUSIONS In India’s government TB program, 99DOTS had high acceptance by HCPs but variable acceptance by TB patients. While some factors contributing to suboptimal patient acceptance are modifiable, other factors—such as TB- and HIV-related stigma and poor cellphone accessibility, cellular signal, and literacy—are more difficult to address. Screening for these barriers may facilitate targeting of 99DOTS to patients more likely to use this technology. CLINICALTRIAL

Acceptability and feasibility of digital adherence technologies for tuberculosis treatment supervision: A meta-analysis of implementation feedback

“…Thomas et al reported similar findings among HCWs at government-run TB centers in India. 24 Stigma related to taking TB medication contributed to lower opportunity scores, reflecting the known impact of stigma on TB care. 25 In addition to stigma, barriers to the feasibility of implementing DATs included technical issues with phones, network connectivity, and issues with the two DAT platforms.…”

“…Similar technical barriers have been reported previously in China, India, Peru, and sub-Saharan Africa. 24,[26][27][28][29] Our analysis had some limitations. First, surveys were administered only to a subset of people with TB in each project.…”

The Performance of Digital Technologies for Measuring Tuberculosis Medication Adherence: A Systematic Review

“…Suboptimal engagement with DATs-which may result in under-reporting of true medication adherence (i.e., reduced sensitivity, reduced NPV)-can be influenced by limited access to mobile networks and technology, shared cellphone use among multiple household members, and inadequate education on the purpose and appropriate use of the DAT. (40)(41)(42)(43) With substantial under-reporting of medication adherence, healthcare providers may have difficulty identifying people who are truly experiencing nonadherence, be unable to routinely reach out to all people with reported nonadherence (e.g., via phone calls or home visits) (44), and may begin to ignore digital adherence data due to its limited performance (42,44).…”

Barriers to engagement by people with active tuberculosis in the care cascade in India: a systematic review of two decades of quantitative research

“…First, consistent with findings from clinical trials [20,180,181], non-adherence to TB medications was independently associated with increased risk of unfavorable treatment outcomes (Gap 4) [81,84,93,97,98,121] and TB recurrence (Gap 5) [158] across multiple Indian studies, which suggests that adherence is a mediator of outcomes in programmatic care. However, measuring TB medication adherence in routine care is challenging, with recent studies from India showing that 99DOTS (a digital adherence technology used in the NTEP) and patient self-report have suboptimal accuracy [182][183][184]. Use of novel approaches for detecting nonadherence, such as urine isoniazid testing [29,185], may facilitate early identification of patients at risk for poor outcomes, so that they can be provided with additional support.…”