Highlights Demand among smallholder farmers in Kenya for improved storage bags is elastic. Lowering the price of the bag by 20% leads to a 29% increase in profit. Prior awareness of the technology increases mean willingness to pay by 20%. Medium by which information is disseminated does not affect willingness to pay. Cheapest media option, text message, is most cost-effective.
Background Digital adherence technologies have been widely promoted as a means to improve tuberculosis medication adherence. However, uptake of these technologies has been suboptimal by both patients and health workers. Not surprisingly, studies have not demonstrated significant improvement in treatment outcomes. Objective This study aimed to optimize a well-known digital adherence technology, 99DOTS, for end user needs in Uganda. We describe the findings of the ideation phase of the human-centered design methodology to adapt 99DOTS according to a set of design principles identified in the previous inspiration phase. Methods 99DOTS is a low-cost digital adherence technology wherein tuberculosis medication blister packs are encased within an envelope that reveals toll-free numbers that patients can call to report dosing. We identified 2 key areas for design and testing: (1) the envelope, including the form factor, content, and depiction of the order of pill taking; and (2) the patient call-in experience. We conducted 5 brainstorming sessions with all relevant stakeholders to generate a suite of potential prototype concepts. Senior investigators identified concepts to further develop based on feasibility and consistency with the predetermined design principles. Prototypes were revised with feedback from the entire team. The envelope and call-in experience prototypes were tested and iteratively revised through focus groups with health workers (n=52) and interviews with patients (n=7). We collected and analyzed qualitative feedback to inform each subsequent iteration. Results The 5 brainstorming sessions produced 127 unique ideas that we clustered into 6 themes: rewards, customization, education, logistics, wording and imagery, and treatment countdown. We developed 16 envelope prototypes, 12 icons, and 28 audio messages for prototype testing. In the final design, we altered the pill packaging envelope by adding a front flap to conceal the pills and reduce potential stigma associated with tuberculosis. The flap was adorned with either a blank calendar or map of Uganda. The inside cover contained a personalized message from a local health worker including contact information, pictorial pill-taking instructions, and a choice of stickers to tailor education to the patient and phase of treatment. Pill-taking order was indicated with colors, chevron arrows, and small mobile phone icons. Last, the call-in experience when patients report dosing was changed to a rotating series of audio messages centered on the themes of prevention, encouragement, and reassurance that tuberculosis is curable. Conclusions We demonstrated the use of human-centered design as a promising tool to drive the adaptation of digital adherence technologies to better address the needs and motivations of end users. The next phase of research, known as the implementation phase in the human-centered design methodology, will investigate whether the adapted 99DOTS platform results in higher levels of engagement from patients and health workers, and ultimately improves tuberculosis treatment outcomes.
Background: 99DOTS is a cellphone-based digital adherence technology. The state of Himachal Pradesh, India, made 99DOTS available to all adult patients with drug-sensitive tuberculosis (TB) in May 2018. While 99DOTS has engaged over 300,000 patients across India, few studies have evaluated its impact on TB treatment outcomes. Methods: We compared treatment outcomes of adult patients with drug-sensitive TB before and after Himachal Pradesh’s 99DOTS launch using data from India’s national TB database. Pre-intervention group patients initiated treatment between February and October 2017 (N=7722), and post-intervention group patients between July 2018 and March 2019 (N=8322). We analyzed patient engagement with 99DOTS and used multivariable logistic regression to estimate impact on treatment outcomes. Results: 2746 (33.0%) post-intervention group patients called 99DOTS at least once, on average calling on 58.5% of treatment days. In the pre-intervention group, 7186 (93.1%) had favorable treatment outcomes, compared to 7734 (92.9%) in the post-intervention group. This difference was not statistically significant (OR=0.981, 95%CI 0.869-1.108), including after controlling for patient characteristics (adjusted OR=0.970, 95%CI 0.854-1.102). Conclusions: We found no statistically significant difference in treatment outcomes before and after a large-scale implementation of 99DOTS. This result can be informative for programs seeking to design and prioritize impactful adherence interventions.
Ensuring that patients adhere to prescribed medication remains an important challenge in global health. While technology has been utilized to monitor and improve adherence, solutions to date have been too costly for large-scale deployment in developing regions. This paper describes 99DOTS, a low-cost approach for tracking adherence using a combination of paper packaging and low-end mobile phones. Every day, patients reveal an unpredictable phone number behind the pills and send a free call to that number to indicate that drugs were dispensed and taken. Within five years of its inception, 99DOTS has become a standard of care for tuberculosis in India and has enrolled over 200,000 patients. We provide a holistic account of the project's evolution, including its iterative design, scaled implementation, and lessons learned along the way. We hope this account will serve as a useful case study for anyone seeking to establish and scale new low-cost technologies for a global audience.
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