Impact of the 99DOTS digital adherence technology on tuberculosis treatment outcomes in North India: a pre-post study.

BACKGROUND: 99DOTS is a cellphone-based digital adherence technology. The state of Himachal Pradesh, India, made 99DOTS available to all adults being treated for drug-sensitive tuberculosis (TB) in the public sector in May 2018. While 99DOTS has engaged over 500,000 people across India, few studies have evaluated its effectiveness in improving TB treatment outcomes. METHODS: We compared treatment outcomes of adults with drug-sensitive TB before and after Himachal Pradesh's 99DOTS launch using data from India's national TB database. The pre-intervention group initiated treatment between February and October 2017 (N = 7722), and the post-intervention group between July 2018 and March 2019 (N = 8322). We analyzed engagement with 99DOTS and used multivariable logistic regression to estimate impact on favorable treatment outcomes (those marked as cured or treatment complete). RESULTS: In the post-intervention group, 2746 (33.0%) people called 99DOTS at least once. Those who called did so with a wide variation in frequency (< 25% of treatment days: 24.6% of callers; 25-50% of days: 15.1% of callers, 50-75% of days: 15.7% of callers; 75-100% of days: 44.6% of callers). In the pre-intervention group, 7186 (93.1%) had favorable treatment outcomes, compared to 7734 (92.9%) in the post-intervention group. This difference was not statistically significant (OR = 0.981, 95% CI [0.869, 1.108], p = 0.758), including after controlling for individual characteristics (adjusted OR = 0.970, 95% CI [0.854, 1.102]). CONCLUSIONS: We found no statistically significant difference in treatment outcomes before and after a large-scale implementation of 99DOTS. Additional work could help to elucidate factors mediating site-wise variations in uptake of the intervention.

Community-Centered Assessment to Inform Pandemic Response in Georgia (US).

The Georgia Community Engagement Alliance (CEAL) Against COVID-19 Disparities Project conducts community-engaged research and outreach to address misinformation and mistrust, to promote inclusion of diverse racial and ethnic populations in clinical trials and increase testing and vaccination uptake. Guided by its Community Coalition Board, The GEORGIA CEAL Survey was administered among Black and Latinx Georgia 18 years and older to learn about community knowledge, perceptions, understandings, and behaviors regarding COVID-19 testing and vaccines. Survey dissemination occurred using survey links generated through Qualtrics and disseminated among board members and other statewide networks. Characteristics of focus counties were (a) highest proportion of 18 years and older Black and Latinx residents; (b) lowest COVID-19 testing rates; and (c) highest SVI values. The final sample included 2082 surveyed respondents. The majority of participants were men (57.1%) and Latinx (62.8%). Approximately half of the sample was aged 18-30 (49.2%); the mean age of the sample was 33.2 years (SD = 9.0), ranging from 18 to 82 years of age. Trusted sources of COVID-19 information that significantly predicted the likelihood of vaccination included their doctor/health care provider (p-value: 0.0054), a clinic (p-value: 0.006), and university hospitals (p-value: 0.0024). Latinx/non-Latinx, Blacks vs. Latinx, Whites were significantly less likely to get tested and/or vaccinated. Non-Latinx, Blacks had higher mean knowledge scores than Latinx, Whites (12.1 vs. 10.9, p < 0.001) and Latinx, Blacks (12.1 vs. 9.6, respectively, p < 0.001). The mean knowledge score was significantly lower in men compared to women (10.3 vs. 11.0, p = 0.001), in those who had been previously tested for COVID-19 compared to those who had never been tested (10.5 vs. 11.5, respectively, p = 0.005), and in those who did not receive any dose of vaccination compared to those who were fully vaccinated (10.0 vs. 11.0, respectively, p < 0.001). These data provide a benchmark for future comparisons of the trajectory of public attitudes and practices related to the COVID-19 pandemic. They also point to the importance of tailoring communication strategies to specific cultural, racial, and ethnic groups to ensure that community-specific barriers to and determinants of health-seeking behaviors are appropriately addressed.

Iterative Adaptation of a Tuberculosis Digital Medication Adherence Technology to Meet User Needs: Qualitative Study of Patients and Health Care Providers Using Human-Centered Design Methods.

BACKGROUND: Digital adherence technologies have been widely promoted as a means to improve tuberculosis medication adherence. However, uptake of these technologies has been suboptimal by both patients and health workers. Not surprisingly, studies have not demonstrated significant improvement in treatment outcomes. OBJECTIVE: This study aimed to optimize a well-known digital adherence technology, 99DOTS, for end user needs in Uganda. We describe the findings of the ideation phase of the human-centered design methodology to adapt 99DOTS according to a set of design principles identified in the previous inspiration phase. METHODS: 99DOTS is a low-cost digital adherence technology wherein tuberculosis medication blister packs are encased within an envelope that reveals toll-free numbers that patients can call to report dosing. We identified 2 key areas for design and testing: (1) the envelope, including the form factor, content, and depiction of the order of pill taking; and (2) the patient call-in experience. We conducted 5 brainstorming sessions with all relevant stakeholders to generate a suite of potential prototype concepts. Senior investigators identified concepts to further develop based on feasibility and consistency 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=52) and interviews with patients (n=7). We collected and analyzed qualitative feedback to inform each subsequent iteration. RESULTS: The 5 brainstorming sessions produced 127 unique ideas that we clustered into 6 themes: rewards, customization, education, logistics, wording and imagery, and treatment countdown. We developed 16 envelope prototypes, 12 icons, and 28 audio messages for prototype testing. In the final design, we altered the pill packaging envelope by adding a front flap to conceal the pills and reduce potential stigma associated with tuberculosis. 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 on the themes of prevention, encouragement, and reassurance that tuberculosis is curable. CONCLUSIONS: We demonstrated the use of human-centered design as a promising tool to drive the adaptation of digital adherence technologies to better address the needs and motivations of end users. The next phase of research, known as the implementation phase in the human-centered design methodology, will investigate whether the adapted 99DOTS platform results in higher levels of engagement from patients and health workers, and ultimately improves tuberculosis treatment outcomes.

What drives smallholder farmers' willingness to pay for a new farm technology? Evidence from an experimental auction in Kenya.

We use an incentive compatible experimental auction to measure demand for a new agricultural technology, a triple layered hermetic storage bag. When used properly, the bag creates an airtight seal that reduces storage loss from insect pests and neutralizes aflatoxin contamination in stored grain. We find that demand for this new technology is highly elastic (4.3) and that the wholesaler could increase profit by lowering the price. We also find that farmers' valuation for the bag is not significantly different based on the medium through which information about it is communicated to them, either text, audio or video messages. This suggests that practitioners should use the cheapest option for disseminating information, which is text messaging in this context. In addition, we find that farmers who have prior awareness of the bag are willing to pay 20% more on average than those previously unaware of it. In total, the highly elastic demand for the improved bags, along with the fact that prior awareness of the bag leads to higher willingness to pay, suggests that a one-time price subsidy for the new technology could spur demand and increase future adoption.