Adaptation of a Smartphone-Based Mobile Health Program to Support Person-Centered Treatment of Tuberculosis in Kilimanjaro, Tanzania: Preimplementation Qualitative Needs Assessment.

Abstract

Despite increasing smartphone penetration worldwide, personalized mHealth (mobile health) care interventions remain largely untapped for the support of people with tuberculosis. An evidence-based multifeature smartphone platform for HIV care tailored and widely implemented in the United States may enhance treatment quality and completion in the Kilimanjaro context. We aimed to evaluate contextual determinants of mHealth implementation in the Kilimanjaro region to ensure feasibility, acceptability, and effective adaptation of the platform for tuberculosis care within Kilimanjaro. We conducted semistructured in-depth interviews at Kilimanjaro Christian Medical Centre and Kibong'oto Infectious Diseases Hospital with people with tuberculosis (aged 18+ years with drug-susceptible/-resistant tuberculosis, with or without HIV, and >1 mo on treatment) and providers and staff (eg, clinicians, community health workers, or laboratory staff). Interview guides were designed using Bury's Framework for Chronic Illness and the Consolidated Framework for Implementation Research, along with an overview of an existing smartphone-based program called PositiveLinks. Interviews were analyzed using thematic analysis, and determinants were mapped to behavior change frameworks to develop a mechanistic understanding of P adaptation for the context. We conducted 14 interviews with people with tuberculosis and 11 provider and staff interviews. Several unmet tuberculosis treatment needs emerged, along with suggestions for platform adaptation and implementation strategies. Findings suggest high personal smartphone access among providers and staff (11/11, 100%), less so for people with tuberculosis interviewed (5/14, 36%). High provider digital literacy and capability and usage were noted, with smartphone apps routinely used for tuberculosis care delivery independent of electronic health systems. People with tuberculosis primarily used mobile phones for communication (calls) with clinic providers and staff for care coordination (eg, reminders). Internet access and stability remain major barriers in rural clinics, along with the personal cost of data bundles for both stakeholder groups. Key assets identified within the inner setting of Kilimanjaro Christian Medical Centre and Kibong'oto Infectious Diseases Hospital include existing provider and staff commitment to treatment support outside of clinic visits, and a robust infrastructure of community outreach for support of adherence and retention for people with tuberculosis. Findings suggest a role for broader digital wraparound support beyond adherence monitoring for tuberculosis care in the context. Real-world considerations for the context suggest implementation of provider-facing smartphone interventions was perceived as highly feasible and acceptable, with appropriate consideration of personal cost associated with usage among stakeholders. Patient-facing or bidirectional tools would require modifications to existing mHealth implementation strategies, including more comprehensive assessment of digital literacy and related training, as well as provision of subsidized devices and data bundles.