Adapting, Refining, and Piloting an Interactive Digital Adherence Technology to Facilitate Patient-Centered Tuberculosis Care in Papua, Indonesia

Abstract

Background: Tuberculosis (TB) was responsible for approximately 1.3 million deaths globally in 2022, making it the leading cause of mortality among individuals with HIV and a significant contributor to deaths associated with antimicrobial resistance. Adherence to the full treatment regimen is essential to prevent the development of resistance and improve cure rates. In Papua, the eastmost province in Indonesia, TB treatment success rates have consistently fallen short of national standards. The World Health Organization recommends Digital Adherence Technology (DAT) as one of the patient-centered care approaches. One such tool currently under evaluation is the Tuberculosis Treatment Support Tools (TB-TST), which combines mobile applications for patients and providers with a home-based urine test to detect drug metabolites and confirm adherence remotely. The increasing internet access and smartphone ownership in Papua highlights the potential for utilizing this tool. However, adaptation and refinement are necessary to ensure its effective implementation in Papuan communities.Purpose: The primary objectives of this dissertation were to adapt, refine, and evaluate the TB-TST to facilitate and enhance patient-centered TB care in Papua. Method: This dissertation employed a multi-phase approach. First, a scoping review was conducted to identify gaps in TB mHealth apps in Indonesia. This review informed the adaptation and refinement phase, which utilized thematic analysis to categorize app features and functionality. Second, the TB-TST was adapted and refined through three rapid iteration phases for patient and provider interfaces. This process involved participatory design activities with design experts and end-users (TB patients and providers) and included usability testing. Third, through a single-arm prospective pilot study, the final phase assessed the usability, feasibility, acceptability, and further refinement of the refined TB-TST (Samocare app). Results: study 1: The scooping review of TB mHealth apps in Indonesia highlighted a lack of patient-centered applications that facilitate communication and collaboration between patients and providers or include strategies to verify treatment adherence. Additionally, none of the applications identified were tailored or tested for end-users in Papua. Study 2: In the second study, we addressed the gap identified in the first study by adapting and refining the TB-TST to be culturally and contextually appropriate for the community in Papua. Study 3: The findings of the third study suggested that the Samocare intervention was feasible, acceptable, and perceived as useful. Patients and treatment supporters reported that the application facilitated patient-centered care by improving communication and providing tailored support. Conclusion: The findings from this study offer preliminary evidence suggesting that transforming TB care in Papua is now achievable/feasible. This study is the first to employ Human-Centered Design principles through rigorous, iterative research phases involving end-users (TB patients and care providers) and design experts in Papua. Although the final test demonstrated the intervention's usefulness, feasibility, and acceptability, further research is necessary. Specifically, a larger, adequately powered clinical trial is required to test the intervention comprehensively, and implementation research is needed to evaluate its effectiveness and sustainability in improving TB care in Papua.