Barriers and facilitators to implementing a digital adherence technology for tuberculosis treatment supervision in Uganda (Preprint)

Abstract

Ensuring completion of treatment for tuberculosis (TB) remains a key challenge in many high-burden countries. 99DOTS is a low-cost digital adherence technology (DAT) that has emerged as a promising tool for monitoring and supporting TB treatment completion.

We conducted a qualitative study with TB patients, health workers, and other stakeholders to assess the feasibility and acceptability of 99DOTS and to characterize barriers and facilitators to its implementation as part of a pragmatic trial in Uganda.

Methods: Between April 2021 and August 2021, we conducted in-depth interviews (IDIs) with 30 TB patients and key informant interviews (KIIs) with 12 health workers and 7 other stakeholders involved in the implementation of 99DOTS at 18 health facilities in Uganda. Semi-structured interview guides were informed by the COM-B model (Capability, Opportunity, Motivation, Behavior) and explored perceptions of and experiences with 99DOTS including barriers and facilitators to its use. Qualitative analysis was conducted using the framework approach.

All participants noted that 99DOTS offered patients support and encouragement to take their anti-TB medication, facilitated treatment monitoring, and improved patient and health worker relationships. Participants also liked that the platform was free, easy to use, and improved TB treatment outcomes. Barriers to 99DOTS implementation for some patients were related to limited literacy including technology literacy; limited access to electricity to charge one’s phone to make dosing confirmation calls; and poor network connection. Gender differences in 99DOTS uptake also emerged. Specifically, female patients were described to fear that 99DOTS use would expose them to TB stigma, and had limited access to phones, including because their male partners confiscated the phone given to them by the study. In contrast, men were noted to have access to phones and substantial support from their female partners to take their anti-TB medications and make 99DOTS dosing confirmation calls. Finally, although women were described to face more barriers to 99DOTS use than men, their narratives centered on the ways the platform facilitated and improved their adherence, whereas men’s narratives did not. Conclusion: 99DOTS appears to be a feasible and acceptable strategy to support anti-TB medication adherence in Uganda. However, our findings point to the need for more material and social support services to women accessing phone-based DATs, and programmatic efforts to address TB stigma and inequitable gender norms. Finally, given the barriers related to access to phones, electricity, and network connection, as well as the gender-based barriers, it is possible that DATs that do not require mobile phones may be needed to maximize uptake.

99DOTS appears to be a feasible and acceptable strategy to support anti-TB medication adherence in Uganda. However, our findings point to the need for more material and social support services to women accessing phone-based DATs, and programmatic efforts to address TB stigma and inequitable gender norms. Finally, given the barriers related to access to phones, electricity, and network connection, as well as the gender-based barriers, it is possible that DATs that do not require mobile phones may be needed to maximize uptake.