Digital Adherence Technologies and Mobile Money Incentives for Management of Tuberculosis Medication Among People Living With Tuberculosis: Mixed Methods Formative Study

Abstract

Abstract

Background: Although there is an increasing use of digital adherence technologies (DATs), such as real-time monitors and
SMS reminders in tuberculosis medication adherence, suboptimal patient engagement with various DATs has been reported.
Additionally, financial constraints can limit DAT’s utility. The perceived usefulness and the design mechanisms of DATs linked
to mobile money financial incentives for tuberculosis medication management remain unclear.

Objective: The aim of this study is to describe the perceived usefulness and design mechanisms for a DAT intervention called
My Mobile Wallet, which is composed of real-time adherence monitors, SMS reminders, and mobile money incentives to support
tuberculosis medication adherence in a low-income setting.

Methods: This study used mixed methods approaches among persons with tuberculosis recruited from the Tuberculosis Clinic
in the Mbarara Regional Referral Hospital. We purposively sampled 21 persons with tuberculosis aged 18 years and older, who
owned cell phones and were able to use SMS text messaging interventions. We also enrolled 9 participants who used DATs in
our previous study. We used focus group discussions with the 30 participants to solicit perceptions about the initial version of
the My Mobile Wallet intervention, and then iteratively refined subsequent versions of the intervention following a user-centered
design approach until the beta version of the intervention that suited their needs was developed. Surveys eliciting information
about participants’ cell phone use and perceptions of the intervention were also administered. Content analysis was used to
inductively analyze qualitative data to derive categories describing the perceived usefulness of the intervention, concerns, and
design mechanisms. Stata (version 13; StataCorp) was used to analyze survey data.

Results: Participants expressed the perceived usefulness of the My Mobile Wallet intervention in terms of being reminded to
take medication, supported with transport to the clinic, and money to meet other tuberculosis medication–related costs, all of
which were perceived to imply care, which could create a sense of connectedness to health care workers. This could consequently
cause participants to develop a self-perceived need to prove their commitment to adherence to health care workers who care for
them, thereby motivating medication adherence. For fear of unintended tuberculosis status disclosure, 20 (67%) participants
suggested using SMS language that is confidential—not easily related to tuberculosis. To reduce the possibilities of using the
money for other competing demands, 25 (83%) participants preferred sending the money 1-2 days before the appointment to limit
the time lag between receiving the money and visiting the clinic.