Our study explored the potentials of mHealth in fostering PPM in Uganda. Overall, key informants discussed the potentials of mHealth technologies in fostering PPM in TB care. mHealth technologies (such as mobile apps, text messages) have the potential to map and link patients from private hospitals to the referral units, support patient care and medication adherence, as well as notify and report TB cases to the Ugandan Ministry of Health.
Meaning Of The Study And Comparison With Other Studies
The potential of mHealth to map and link referred patients to the referral points could eliminate the risk of loss of patients along the pathway of care but could also result in enhanced patient care and monitoring. Through such mHealth interventions, the proportion of patients that reach their expected referral points and who get started on medication on time could increase, with subsequent reductions in diagnostic and drug initiation delays. Most of the private hospitals in Uganda are not accredited to provide TB services, this limits their efforts and engagement in TB care despite being at the center of receiving a majority (48.4%) of the population who seek healthcare compared to the government (public) health facilities (34%) . Therefore, as a common practice, most of these private hospitals refer presumptive TB patients to public hospitals . However, the lack of mechanisms for following up these patients in private hospitals  still stifles TB control efforts. In this regard, the adoption of the current ICT technologies like smartphones, mobile apps (mHealth) as a mechanism for following up these patients after referral could ensure easier patient tracking and successful referral processes from private to public health facilities. For example, the use of telephone calls as a measure for following up the referred TB patients from private facilities to the peripheral units has been reported in Cambodia and resulted in increased retention of the referred TB patients . In India the utilization of a smartphone application by rural private healthcare practitioners to refer patients to TB microscopy Centre located at public health facilities resulted in an increased number of referrals, reduced time taken for diagnosis, and treatment initiation . However, on the other hand, the implementation and utilization of mHealth in fostering PPM in Africa remain unknown, yet most countries in Africa still grapple with a high number of TB cases (25% of the global TB cases come from Africa) . Understanding how mHealth is utilized to engage the private sector in TB care especially in African settings has the potential to ensure better TB disease outcomes in Africa.
The potential of mHealth in supporting patient care and medication adherence among TB patients could enhance timely in-take of medication and the attendance of hospital appointments for pill refills. Particularly in our study, participants reported that mHealth technology would enable healthcare workers to monitor patients thus enabling adherence to medication and attendance of hospital appointments. mHealth provides quick access to information for both patients and healthcare workers and offers a qualitative and quantitative interaction between the healthcare providers and the patients . Several studies utilizing mHealth technologies for supporting medication adherence among both TB and HIV patients have been conducted in Uganda [19, 27] and were found to be acceptable and feasible. A randomized control trial  that was conducted in Karachi Pakistan utilized two-way short message service (SMS) reminders to encourage newly diagnosed patients from public and private health facilities to take their medication. However, the utilization of mHealth technologies between the public and private health facilities in Uganda for TB care is unknown. This leaves a research gap and calls for a special investigation on how mHealth technologies can be utilized for enhancing PPM in TB care.
Our study findings report that mHealth interventions could also enhance quick and timely notification of TB cases from the private health facilities to national TB programs to ensure better planning of TB management services. Notifying cases is key in enhancing the tracking and management of the patients. TB case notification rate in Uganda is mostly done by public hospitals (86%), while private for-profit facilities notify only 1% . The report shows that most of the cases are still missed where about 30,000 people with TB symptoms were neither notified nor diagnosed in 2018/19. This implies a need for establishing mechanisms for ensuring that all cases are notified. mHealth could play a role in improving notification of every diagnosed case as shown in the literature. According to a scoping review by Tumuhimbise and Musiimenta, mHealth interventions like mobile applications have been utilized in the notification of TB cases in Vietnam India, Indonesia, Pakistan, and Vietnam . A referral and reporting back mobile phone application was found to be acceptable and feasible for notifying TB cases among the private practitioners in Indonesia . Although mHealth has been utilized in the notification of TB cases elsewhere, its experience among healthcare workers in settings like Uganda where healthcare workers might be overwhelmed with a large number of clients (high patient-doctor ratio) and fail to find time for real-time use of the application to notify cases; this is being explored in our ongoing research investigation.
In this study, participants raised concerns about the lack of knowledge to use the developed mobile applications. User involvement during intervention development may play a role in acquainting system end-users with the intervention which in the long run will facilitate the acceptability of the developed application among users . This approach helps the developers to understand user behaviors, requirements, and skills at each phase of the design . Training users on how to use the application before implementation may improve usability and address this concern. Users who are not well trained to use find it hard to use the technology . Therefore, system implementers should ensure conducting initial training sessions before rolling out the interventions. In addition, developers should develop interventions that are easy to use  which are intended to ease the work of healthcare workers.
The reported poor internet connectivity or lack of internet access especially for interventions that entirely run on the internet or require the internet to function can hinder the usability of the application and result in abandonment of the interventions. mHealth interventions that entirely rely on the internet to operate, require stable internet connections to ensure thorough operability. The jurisdiction of the cost burden of internet packages for running these internet-based interventions must be clearly defined lest the cost burden on the users can’t be sustained in the long run. mHealth interventions should at all costs remove the cost burden from the users if the successful implementation is to be ensured. Considering the development of standalone interventions or applications that do not require the internet to operate can address this concern.
The general implementation and coverage of PPM for TB in Uganda require deliberate efforts to ensure that all private health facilities are involved in TB care if success and better health outcomes are to be realized. Engaging and empowering the private sector in TB disease management is crucial in enhancing the reduction of unnecessary deaths and sufferings due to substandard diagnosis, inappropriate treatment, and care that occur in the private sector, thus reduction in catastrophic costs . Successful TB control efforts cannot be achieved globally if the private providers are not brought on board to tackle TB disease.
Strength of the study
This study has several strengths; first, it identifies key insights about the potentials of mHealth technologies from the front line private medical healthcare workers in a low resource setting which provides an evidence base for the development of future interventions in similar settings. Secondly, to the best of our knowledge, this study is the first to report pre-intervention perceptions of healthcare workers from the private hospitals about the potentials of mHealth technologies for fostering PPM in TB care. Third, our findings are important for understanding the optimal design of future mHealth interventions to facilitate sustainable PPM in TB care.
Limitations of the study
Our study is not without limitations that should be considered during the interpretation of our research findings. First, being a formative study, the investigator solicited the perceptions of private healthcare workers about using mHealth in TB care before they could use the intervention in real life. The results, therefore, do not document the practical real-life experiences of utilizing the mHealth intervention in TB care. Second, our study employed a purposive sampling approach for recruiting key informants, which has the potential for selection bias. Lastly, this study was conducted in private hospitals in an urban setting; this could limit the generalizability of our findings in rural settings, where private hospital operations and practices might be different.
Implications for policy and practice makers
The utilization of mHealth in TB care among private hospitals in Uganda is lacking. This limits the realization of mHealth benefits in the achievement of better TB treatment outcomes and the realization of PPM. Our findings imply that mHealth has the potential to revolutionize TB care by establishing a centralized pathway for linking the referred patients from private to public hospitals and ensuring that they are not lost along the TB care pathway, have been diagnosed, and started on medication. Our study implies that mHealth can be a cost-effective solution for enhancing the full integration and engagement of the private healthcare facilities in TB care thus the achievement of PPM.
The implementation of the mHealth interventions requires training of users to equip them with skills to enable intervention acceptability and usability. mHealth interventions that entirely rely on the internet to operate, require stable internet connections to ensure thorough operability. Standalone applications that do not require the internet to operate can offer better alternatives. mHealth interventions should at all costs remove the cost burden from the users if the successful implementation is to be ensured.
Our findings recognize that there is a need for future researchers to assess the utilization of mHealth for following up patients that have been referred from the private hospitals in African settings to ascertain its effectiveness on TB care outcomes and its contribution to the PPM effort for TB care.
Unanswered questions and future research
Exploring the real-life experiences of how mHealth can be used to foster the establishment of PPM in rural Uganda is key in informing policy formulation to address TB care outcomes.