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Gupta AJ, Turimumahoro P, Ochom E, Ggita JM, Babirye D, Ayakaka I, Mark D, Okello DA, Cattamanchi A, Dowdy DW, Haberer JE, Armstrong-Hough M, Katamba A, Davis JL. mHealth to improve implementation of TB contact investigation: a case study from Uganda. Implement Sci Commun 2023; 4:71. [PMID: 37340456 PMCID: PMC10280918 DOI: 10.1186/s43058-023-00448-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 06/01/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Implementation science offers a systematic approach to adapting innovations and delivery strategies to new contexts but has yet to be widely applied in low- and middle-income countries. The Fogarty Center for Global Health Studies is sponsoring a special series, "Global Implementation Science Case Studies," to address this gap. METHODS We developed a case study for this series describing our approach and lessons learned while conducting a prospective, multi-modal study to design, implement, and evaluate an implementation strategy for TB contact investigation in Kampala, Uganda. The study included formative, evaluative, and summative phases that allowed us to develop and test an adapted contact investigation intervention involving home-based sample collection for TB and HIV testing. We concurrently developed a multi-component mHealth implementation strategy involving fingerprint scanning, electronic decision support, and automated reporting of test results via text message. We then conducted a household-randomized, hybrid implementation-effectiveness trial comparing the adapted intervention and implementation strategy to usual care. Our assessment included nested quantitative and qualitative studies to understand the strategy's acceptability, appropriateness, feasibility, fidelity, and costs. Reflecting on this process with a multi-disciplinary team of implementing researchers and local public health partners, we provide commentary on the previously published studies and how the results influenced the adaptation of international TB contact investigation guidelines to fit the local context. RESULTS While the trial did not show improvements in contact investigation delivery or public health outcomes, our multi-modal evaluation strategy helped us identify which elements of home-based, mHealth-facilitated contact investigation were feasible, acceptable, and appropriate and which elements reduced its fidelity and sustainability, including high costs. We identified a need for better tools for measuring implementation that are simple, quantitative, and repeatable and for greater attention to ethical issues in implementation science. CONCLUSIONS Overall, a theory-informed, community-engaged approach to implementation offered many learnings and actionable insights for delivering TB contact investigation and using implementation science in low-income countries. Future implementation trials, especially those incorporating mHealth strategies, should apply the learnings from this case study to enhance the rigor, equity, and impact of implementation research in global health settings.
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Affiliation(s)
- Amanda J Gupta
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Patricia Turimumahoro
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Emmanuel Ochom
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Joseph M Ggita
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Diana Babirye
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Irene Ayakaka
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - David Mark
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | | | - Adithya Cattamanchi
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA
- Division of Pulmonary Diseases and Critical Care Medicine, University of California, Irvine, Irvine, CA, USA
| | - David W Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jessica E Haberer
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mari Armstrong-Hough
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, NY, USA
- Department of Epidemiology, New York University School of Global Public Health, New York, NY, USA
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
- Clinical Epidemiology Unit, Department of Medicine, Makerere University, Kampala, Uganda
| | - J Lucian Davis
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.
- Pulmonary, Critical Care, and Sleep Medicine Section, Yale School of Medicine, New Haven, CT, USA.
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, CT, USA.
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Turimumahoro P, Tucker A, Gupta AJ, Tampi RP, Babirye D, Ochom E, Ggita JM, Ayakaka I, Sohn H, Katamba A, Dowdy D, Davis JL. A cost analysis of implementing mobile health facilitated tuberculosis contact investigation in a low-income setting. PLoS One 2022; 17:e0265033. [PMID: 35363783 PMCID: PMC8975098 DOI: 10.1371/journal.pone.0265033] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/22/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Mobile health (mHealth) applications may improve timely access to health services and improve patient-provider communication, but the upfront costs of implementation may be prohibitive, especially in resource-limited settings. Methods We measured the costs of developing and implementing an mHealth-facilitated, home-based strategy for tuberculosis (TB) contact investigation in Kampala, Uganda, between February 2014 and July 2017. We compared routine implementation involving community health workers (CHWs) screening and referring household contacts to clinics for TB evaluation to home-based HIV testing and sputum collection and transport with test results delivered by automated short messaging services (SMS). We carried out key informant interviews with CHWs and asked them to complete time-and-motion surveys. We estimated program costs from the perspective of the Ugandan health system, using top-down and bottom-up (components-based) approaches. We estimated total costs per contact investigated and per TB-positive contact identified in 2018 US dollars, one and five years after program implementation. Results The total top-down cost was $472,327, including $358,504 (76%) for program development and $108,584 (24%) for program implementation. This corresponded to $320-$348 per household contact investigated and $8,873-$9,652 per contact diagnosed with active TB over a 5-year period. CHW time was spent primarily evaluating household contacts who returned to the clinic for evaluation (median 30 minutes per contact investigated, interquartile range [IQR]: 30–70), collecting sputum samples (median 29 minutes, IQR: 25–30) and offering HIV testing services (median 28 minutes, IQR: 17–43). Cost estimates were sensitive to infrastructural capacity needs, program reach, and the epidemiological yield of contact investigation. Conclusion Over 75% of all costs of the mHealth-facilitated TB contact investigation strategy were dedicated to establishing mHealth infrastructure and capacity. Implementing the mHealth strategy at scale and maintaining it over a longer time horizon could help decrease development costs as a proportion of total costs.
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Affiliation(s)
| | - Austin Tucker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Amanda J. Gupta
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States of America
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Radhika P. Tampi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Diana Babirye
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Emmanuel Ochom
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Joseph M. Ggita
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Irene Ayakaka
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Hojoon Sohn
- Department of Preventative Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Clinical Epidemiology Unit, Makerere University, College of Health Sciences Kampala, Kampala, Uganda
| | - David Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - J. Lucian Davis
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Pulmonary, Critical Care and Sleep Medicine Section, Yale School of Medicine, New Haven, CT, United States of America
- * E-mail:
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Davis JL, Ayakaka I, Ggita JM, Ochom E, Babirye D, Turimumahoro P, Gupta AJ, Mugabe FR, Armstrong-Hough M, Cattamanchi A, Katamba A. Theory-Informed Design of a Tailored Strategy for Implementing Household TB Contact Investigation in Uganda. Front Public Health 2022; 10:837211. [PMID: 35400072 PMCID: PMC8987305 DOI: 10.3389/fpubh.2022.837211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/28/2022] [Indexed: 11/24/2022] Open
Abstract
Since 2012, the World Health Organization has recommended household contact investigation as an evidence-based intervention to find and treat individuals with active tuberculosis (TB), the most common infectious cause of death worldwide after COVID-19. Unfortunately, uptake of this recommendation has been suboptimal in low- and middle-income countries, where the majority of affected individuals reside, and little is known about how to effectively deliver this service. Therefore, we undertook a systematic process to design a novel, theory-informed implementation strategy to promote uptake of contact investigation in Uganda, using the COM-B (Capability-Opportunity-Motivation-Behavior) model and the Behavior Change Wheel (BCW) framework. We systematically engaged national, clinic-, and community-based stakeholders and collectively re-examined the results of our own formative, parallel mixed-methods studies. We identified three core behaviors within contact investigation that we wished to change, and multiple antecedents (i.e., barriers and facilitators) of those behaviors. The BCW framework helped identify multiple intervention functions targeted to these antecedents, as well as several policies that could potentially enhance the effectiveness of those interventions. Finally, we identified multiple behavior change techniques and policies that we incorporated into a multi-component implementation strategy, which we compared to usual care in a household cluster-randomized trial. We introduced some components in both arms, including those designed to facilitate initial uptake of contact investigation, with improvement relative to historical controls. Other components that we introduced to facilitate completion of TB evaluation—home-based TB-HIV evaluation and follow-up text messaging—returned negative results due to implementation failures. In summary, the Behavior Change Wheel framework provided a feasible and transparent approach to designing a theory-informed implementation strategy. Future studies should explore the use of experimental methods such as micro-randomized trials to identify the most active components of implementation strategies, as well as more creative and entrepreneurial methods such as human-centered design to better adapt the forms and fit of implementation strategies to end users.
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Affiliation(s)
- J. Lucian Davis
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, CT, United States
- Pulmonary, Critical Care, and Sleep Medicine Section, Yale School of Medicine, New Haven, CT, United States
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
- *Correspondence: J. Lucian Davis
| | - Irene Ayakaka
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
- Liverpool School of Tropical Medicine, Liverpool School of Tropical Medicine (LSTM) International Multidisciplinary Programme to Address Lung Health and TB in Africa (IMPALA) Program, Liverpool, United Kingdom
| | - Joseph M. Ggita
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emmanuel Ochom
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Diana Babirye
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Patricia Turimumahoro
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Amanda J. Gupta
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Mari Armstrong-Hough
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY, United States
- Department of Epidemiology, School of Global Public Health, New York University, New York, NY, United States
| | - Adithya Cattamanchi
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, United States
- Curry International Tuberculosis Center, University of California, San Francisco, San Francisco, CA, United States
- Division of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Epidemiology Unit, Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Kreniske P, Basmajian A, Nakyanjo N, Ddaaki W, Isabirye D, Ssekyewa C, Nakubulwa R, Hirsch JS, Deisher A, Nalugoda F, Chang LW, Santelli JS. The Promise and Peril of Mobile Phones for Youth in Rural Uganda: Multimethod Study of Implications for Health and HIV. J Med Internet Res 2021; 23:e17837. [PMID: 33528375 PMCID: PMC7886611 DOI: 10.2196/17837] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/18/2020] [Accepted: 11/23/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In East Africa, where landlines are used by 1% of the population and access to the internet is limited, owning a cell phone is rapidly becoming essential for acquiring information and resources. Our analysis illuminates the perils and potential promise of mobile phones with implications for future interventions to promote the health of adolescents and young adults (AYAs) and to prevent HIV infection. OBJECTIVE The aim of this study is to describe the current state of AYAs' phone use in the region and trace out the implications for mobile health interventions. METHODS We identified 2 trading centers that were representative of southern Uganda in terms of key demographics, proportion of cell phone ownership, and community HIV prevalence. We stratified the sample of potential informants by age group (15-19 years and 20-24 years), gender, and phone ownership and randomly sampled 31 key informant interview participants within these categories. In addition, we conducted 24 ethnographic participant observations among AYAs in the communities of study. RESULTS AYA frequently reported barriers to using their phones, such as difficulty accessing electricity. Nearly all AYAs used mobile phones to participate in the local economy and communicate with sexual partners. Phone use was frequently a point of contention between sexual partners, with many AYAs reporting that their sexual partners associated phone use with infidelity. Few AYAs reported using their phones for health-related purposes, with most getting health information in person from health workers. However, most AYAs reported an instance when they used their phone in an emergency, with childbirth-related emergencies being the most common. Finally, most AYAs reported that they would like to use their phones for health purposes and specifically stated that they would like to use their mobile phones to access current HIV prevention information. CONCLUSIONS This study demonstrates how mobile phones are related to income-generating practices in the region and communication with sexual partners but not access to health and HIV information. Our analysis offers some explanation for our previous study, which suggested an association between mobile phone ownership, having multiple sexual partners, and HIV risk. Mobile phones have untapped potential to serve as tools for health promotion and HIV prevention.
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Affiliation(s)
- Philip Kreniske
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY, United States.,Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Alyssa Basmajian
- Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States
| | | | | | | | | | | | - Jennifer S Hirsch
- Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Andrea Deisher
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, United States
| | | | - Larry W Chang
- Rakai Health Sciences Program, Kalisizo, Uganda.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.,Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - John S Santelli
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, United States.,Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
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Meyer AJ, Armstrong-Hough M, Babirye D, Mark D, Turimumahoro P, Ayakaka I, Haberer JE, Katamba A, Davis JL. Implementing mHealth Interventions in a Resource-Constrained Setting: Case Study From Uganda. JMIR Mhealth Uhealth 2020; 8:e19552. [PMID: 32673262 PMCID: PMC7385635 DOI: 10.2196/19552] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/01/2020] [Accepted: 06/21/2020] [Indexed: 12/20/2022] Open
Abstract
Background Mobile health (mHealth) interventions are becoming more common in low-income countries. Existing research often overlooks implementation challenges associated with the design and technology requirements of mHealth interventions. Objective We aimed to characterize the challenges that we encountered in the implementation of a complex mHealth intervention in Uganda. Methods We customized a commercial mobile survey app to facilitate a two-arm household-randomized, controlled trial of home-based tuberculosis (TB) contact investigation. We incorporated digital fingerprinting for patient identification in both study arms and automated SMS messages in the intervention arm only. A local research team systematically documented challenges to implementation in biweekly site visit reports, project management reports, and minutes from biweekly conference calls. We then classified these challenges using the Consolidated Framework for Implementation Research (CFIR). Results We identified challenges in three principal CFIR domains: (1) intervention characteristics, (2) inner setting, and (3) characteristics of implementers. The adaptability of the app to the local setting was limited by software and hardware requirements. The complexity and logistics of implementing the intervention further hindered its adaptability. Study staff reported that community health workers (CHWs) were enthusiastic regarding the use of technology to enhance TB contact investigation during training and the initial phase of implementation. After experiencing technological failures, their trust in the technology declined along with their use of it. Finally, complex data structures impeded the development and execution of a data management plan that would allow for articulation of goals and provide timely feedback to study staff, CHWs, and participants. Conclusions mHealth technologies have the potential to make delivery of public health interventions more direct and efficient, but we found that a lack of adaptability, excessive complexity, loss of trust among end users, and a lack of effective feedback systems can undermine implementation, especially in low-resource settings where digital services have not yet proliferated. Implementers should anticipate and strive to avoid these barriers by investing in and adapting to local human and material resources, prioritizing feedback from end users, and optimizing data management and quality assurance procedures. Trial Registration Pan-African Clinical Trials Registration PACTR201509000877140; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=877
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Affiliation(s)
- Amanda J Meyer
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States.,Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Mari Armstrong-Hough
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Departments of Social and Behavioral Sciences and Epidemiology, School of Global Public Health, New York University, New York, NY, United States
| | - Diana Babirye
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - David Mark
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Patricia Turimumahoro
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Irene Ayakaka
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - Jessica E Haberer
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Clinical Epidemiology and Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - J Lucian Davis
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States.,Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, CT, United States.,Pulmonary, Critical Care and Sleep Medicine Section, Yale School of Medicine, New Haven, CT, United States
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