Iterative Adaptation of a Tuberculosis Digital Medication Adherence Technology to Meet User Needs: Qualitative Study of Patients and Health Care Providers Using Human-Centered Design Methods

Abstract

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.

Digital adherence technology for tuberculosis treatment supervision: A stepped-wedge cluster-randomized trial in Uganda

“…During the intervention period, the decision to offer and accept 99DOTS-based supervision was left to treating providers and patients, respectively. The standard 99DOTS platform was adapted using human-centered design methods in collaboration with local stakeholders and end-users prior to the start of the trial, with further adaptation of the envelope design during the first 2 months of the trial ( S3 Fig ) [ 10 , 11 ]. If enrolled on 99DOTS, patients were given TB medication blister packs placed inside the adapted 99DOTS envelope, received daily automated SMS dosing reminders, and were asked to confirm dosing by making daily toll-free phone calls to the 99DOTS system.…”

“…99DOTS implementation AU : Pleasecheckthattheeditstothesentence99DOTimplementatio and health economic outcomes are described in the trial protocol [8]; implementation and health economic outcomes will be reported later. Previous publications have described the trial protocol [8], baseline TB treatment outcomes at the trial sites [9], and the human-centered design process used to adapt the 99DOTS platform to better meet the needs of patients and health workers [10,11].…”

“…Each row corresponds to a patient. The dataset includes 13 columns: intervention group-randomization block (1)(2)(3)(4)(5)(6); health facility-health facility where the patient initiated treatment (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18); health center-type of facility (health center, hospital); trial month-month during which the patient initiated treatment (0-7); study period (control, buffer, intervention); sex; age; HIV status; disease class (bacteriologically confirmed pulmonary TB, clinically diagnosed pulmonary TB); retreatment -patient type (new, retreatment); treated successfully-primary outcome; persisting on treatment-secondary outcome; not lost to follow-up-secondary outcome.…”

Patient Perceptions on Barriers and Facilitators to Accessing Low-acuity Surgery During COVID-19 Pandemic

“…A resident researcher with training in human-centered design through the UCSF Better Lab trained the other coders in this method. 17,18 Researchers underwent practice rounds during which coding strategy was evaluated. Each researcher developed themes independently, and these were shared with the group along with all raw comments to confirm dependability of thematic analysis.…”

Technology And Its Role In Supporting Tuberculosis Treatment Adherence: A Literature Review

“…Most of these smartphone-based applications have been tested directly in the community with varying effectiveness (Wang et al, 2019) (Iribarren et al, 2021). The use of this technology is not only aimed at patients but also at health workers who serve TB patients (Patel et al, 2020).…”