Accepted for/Published in: JMIR Formative Research
Date Submitted: Apr 17, 2020
Date Accepted: Sep 24, 2020
Iterative adaptation of a tuberculosis digital medication adherence technology to meet user needs using human centered design
ABSTRACT
Background:
Digital Adherence Technologies (DATs) have been widely promoted as a means to improve tuberculosis (TB) medication adherence. However, uptake of DATs has been sub-optimal by both patients and health workers. Not surprisingly, studies have failed to demonstrate significant improvement in treatment outcomes.
Objective:
The goal of this study was to use the human-centered design (HCD) methodology to adapt 99DOTS to a set of design principles identified in a previous phase of research in order to optimize the platform for end-users needs. 99DOTS is a low-cost DAT wherein TB medication blister packs are encased within an envelope that reveals toll-free numbers patients can call to report dosing.
Methods:
Two key areas for design and testing were identified: 1) the envelope – including the form factor, content, and depiction of the order of pill taking; and 2) the patient call-in experience. Five brainstorming sessions with all relevant stakeholders were conducted to generate a suite of potential prototype concepts. Senior investigators identified concepts to further develop based on feasibility and consistentcy 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=54) and interviews with patients (N=7). Qualitative feedback was collected and analyzed to inform each subsequent iteration.
Results:
Five brainstorm sessions produced 127 unique ideas that were clustered into six themes: rewards, customization, education, logistics, wording and imagery, and treatment countdown. Sixteen envelope prototypes, 12 icons, and 28 audio messages were developed for prototype testing. In the final design, the pill packaging envelope form factor was altered to have an additional front flap to conceal the pills and reduce potential stigma associated with TB. 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 around the themes of prevention, encouragement, and reassurance that TB is curable.
Conclusions:
We demonstrate the use of HCD as an optimal tool to drive the adaptation of DATs to better address the needs and motivations of end-users. The next stage of research will investigate whether the adapted 99DOTS platform results in higher levels of engagement from patients and health workers, and ultimately improves TB treatment outcomes. Clinical Trial: N/a
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