Qualitative Evaluation of a Text Messaging Intervention to Support Patients With Active Tuberculosis: Implementation Considerations

Abstract

BackgroundTuberculosis (TB) remains a major global public health problem and mobile health (mHealth) interventions have been identified as a modality to improve TB outcomes. TextTB, an interactive text-based intervention to promote adherence with TB medication, was pilot-tested in Argentina with results supporting the implementation of trials at a larger scale.ObjectiveThe objective of this research was to understand issues encountered during pilot-testing in order to inform future implementation in a larger-scale trial.MethodsA descriptive, observational qualitative design guided by a sociotechnical framework was used. The setting was a clinic within a public pulmonary-specialized hospital in Argentina. Data were collected through workflow observation over 115 days, text messages (n=2286), review of the study log, and stakeholder input. Emerging issues were categorized as organizational, human, technical, or sociotechnical considerations.ResultsIssues related to the intervention included workflow issues (eg, human, training, security), technical challenges (eg, data errors, platform shortcomings), and message delivery issues (eg, unintentional sending of multiple messages, auto-confirmation problems). System/contextual issues included variable mobile network coverage, electrical and Internet outages, and medication shortages.ConclusionsIntervention challenges were largely manageable during pilot-testing, but need to be addressed systematically before proceeding with a larger-scale trial. Potential solutions are outlined. Findings may help others considering implementing an mHealth intervention to anticipate and mitigate certain challenges. Although some of the issues may be context dependent, other issues such as electrical/Internet outages and limited resources are not unique issues to our setting. Release of new software versions did not result in solutions for certain issues, as specific features used were removed. Therefore, other software options will need to be considered before expanding into a larger-scale endeavor. Improved automation of some features will be necessary, however, a goal will be to retain the intervention capability to be interactive, user friendly, and patient focused. Continued collaboration with stakeholders will be required to conduct further research and to understand how such an mHealth intervention can be effectively integrated into larger health systems.

Scoping review and evaluation of SMS/text messaging platforms for mHealth projects or clinical interventions

“…From these authors 6 of the 27 platforms identified above were reported as being used in the studies. CommCare was used in 9 studies [25–33], FrontlineSMS in five [16, 18, 34–36], Sana in three [37–39], Rapid SMS in two [40, 41], and one each for MoTech [42] and Magpi/DataDyne [43]. Few of the articles contained information about the advantages and disadvantages of the platform; most merely mentioned the platform and how it was used in the study.…”

“…For FrontlineSMS, one article reported a number of advantages and disadvantages that are outline in table 3 [16], while the other three articles listing FrontlineSMS as the platform used did not report platform-specific advantages or disadvantages [18, 34, 35]. However, one set of authors described the rationale for selecting FrontlineSMS as the following: it was an open source computer-based application where researchers could log in and manage sending and receiving messages, contact information, user preferences, and passcodes; included a message database and a module to set message reminder frequency; and it supported a global system for mobile communications (GSM) modem to send and receive text messages [18].…”

“…This scoping review consisted of four steps to: 1) identify currently available platforms in mHealth repositories and online searches; 2) expand evaluation criteria from an mHealth mobile messaging toolkit and integrate prior research/user experiences[16–18]; 3) evaluate each platform’s functionalities and features based on the established criteria and a short vendor survey; and 4) assess documentation of platform use in the peer-review literature [22]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for reporting findings of searches [23].…”

“…The Principles for Digital Development [20], the authors’ prior experience using SMS platforms [16–18], and study questions were used to expand the evaluation criteria. First, the toolkit was searched for relevant information and assessment criteria were extracted.…”

“…The driver for this review was the authors’ first-hand experiences using TMI platforms for data collection and participant interactions in the US and in low-resource countries [16–18]. The authors wanted to determine what mHealth platform other researchers used, explore what options were available to mitigate some of the challenges they experienced and determine platform advantages and disadvantages.…”