Acceptability and Feasibility of a Mobile Health Application for Enhancing Public Private Mix for TB care among Healthcare workers in Southwestern Uganda

doi:10.21203/rs.3.rs-1956158/v1

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Acceptability and Feasibility of a Mobile Health Application for Enhancing Public Private Mix for TB care among Healthcare workers in Southwestern Uganda

https://doi.org/10.21203/rs.3.rs-1956158/v1

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Background: Mobile health interventions can potentially enhance public-private linkage for tuberculosis care. However, evidence about their acceptability and feasibility is lacking. Objective: To assess the initial acceptability and feasibility of a mobile health application for following up presumptive tuberculosis patients referred from private to public hospitals. Methods: A total of 22 healthcare workers from three private hospitals and one public hospital in southwestern Uganda were trained and received Tuuka mobile application for a period of one month for testing. Testing focused on a variety of issues such as referring cases by private healthcare workers and receiving cases by public healthcare workers, and sending SMS reminders to the referred patients by filling the digital referral forms inbuilt within the app. Study participants participated in qualitative semi-structured in-depth interviews on the acceptability and feasibility of this app. An inductive, content analytic approach, framed by the unified theory of acceptance and use of technology model, was used to analyze qualitative data. Quantitative feasibility metrics and the quantitative assessment of acceptability were analyzed descriptively using STATA. Results: Healthcare workers found the Tuuka application acceptable and feasible with a mean total system usability scale score of 98 (SD 1.97). The application was perceived to be useful in reminding referred patients to adhere to referral appointments, notifying public hospital healthcare workers about the incoming referred patients, facilitating communication across facilities, and enhancing patient-based care. Conclusion: A mobile health application is acceptable and feasible for following up the referred presumptive tuberculosis patients referred from private to public hospitals in southwestern Uganda. Future efforts should focus on incorporating incentives to motivate and enable sustained use among healthcare workers.

acceptability

feasibility

mobile application

public private mix

tuberculosis

Tuberculosis (TB) is ranked as the 13th leading cause of death globally and the second leading infectious disease after coronavirus disease (COVID-19) (WHO, 2021) despite its being curable and preventable. A total of 10 million people fell ill with TB while 1.5 million deaths were registered globally in 2020. Majority (98%) of these reported cases are in low and middle income countries for example, Africa has the highest TB incidence: 220 (195–245) per 100,000 compared to the rest of the world (WHO, 2021). In Uganda, the TB incidence is at 196 (117–296) per 100,000 and 65 (39–98) per 100,000 among people living with HIV, making it to be among the 30 high TB burden countries and 30 high TB/HIV burden countries (WHO, 2020). Although efforts to control TB care are underway, the public hospitals which are at the forefront of TB care service provision are overwhelmed with high number of patients.

In an effort to enhance commitment to eliminate TB globally, the involvement of the private healthcare facilities has been recommended by the World Health Organization (WHO) as a key sub component of the End TB strategy pillar “bold policies and supportive systems” (WHO, 2015). In 2003, the WHO birthed the Public Private Mix (PPM) in an effort to involve all healthcare providers in the provision of TB care services (Uplekar 2003). PPM involves several strategies and mechanisms that link health entities from both the private and public facilities to the National Tuberculosis and Leprosy programs for the expansion of Directly Observed Treatment Short course (DOTS) activities (WHO, 2021). The PPM implementation globally has resulted in improved notification and retention of TB cases in Nigeria and India respectively (Asuquo et al., 2015, Dewan et al., 2006), and reduced financial burden on patients receiving TB care in the private sector (Anand et al., 2017).

Private hospitals are perceived to be near or within close proximity to patients and to provide high quality of care to patients by ensuring the privacy and confidentiality. However, concerns regarding lack of accreditation and proper follow-up mechanisms, hinder their engagement in TB care (Tumuhimbise and Musiimenta 2021). Majority of these private hospitals refer presumptive TB patients to the government hospitals for better TB management. However, the success of this referral process isn’t guaranteed since majority of private hospitals lack proper follow-up mechanisms for ensuring that TB patients reach the facilities were they referred (Tumuhimbise and Musiimenta 2021). Patients often delay going to referral units due to reluctance to transfer from private to public facilities, with some ending up as lost to follow up on referral (Choun et al 2017 and O’hanlon et al 2016). This has led to increased delayed diagnosis, treatment initiation and consequent increased disease severity, prolonged duration of infectivity and transmission at the household level. This results in catastrophic costs on the side of patients and their families (WHO 2018), increases the risk of drug resistance (Law et al 2017), worsens the patients’ health conditions, and eventually leads to death in the long run (Wood et al, 2010).

The utilization of mHealth technologies have the potential to reduce the amount of time spent at health facilities (Tumuhimbise et al 2020), enhance patients’ medication adherence (Musiimenta et al 2019, Musiimenta et al 2018) and enhance the involvement of the private sector in TB care (Tumuhimbise and Musiimenta 2021b). However, literature regarding their acceptability and feasibility in enhancing PPM especially in African setting remains limited. Several studies have been carried out to assess the feasibility and acceptability of these mHealth interventions elsewhere for example in Indonesia, Lestari and colleagues found a referral and reporting back mobile smartphone application feasible (Lestari et al., 2017). In British Columbia, a pilot intervention study implementing the Weltel intervention utilizing automated SMS messages from a computer system at a clinic was found feasible (van der Kop et al., 2013). However, evidence on the feasibility and acceptability of mHealth interventions for following up the referred presumptive TB patients from private to public hospitals in Uganda are lacking. This paper addresses this gap by exploring the initial acceptability and feasibility of a mobile health intervention for following up presumptive TB patients referred from private to public hospitals in southwestern Uganda.

Ethical Approval

Official permission was obtained from the participating hospitals. Ethical approval was obtained from Mbarara University Research Ethics Committee— MUREC (Protocol number: 32/03-20) and the Uganda National Council of Science and Technology— UNCST (Registration number: HS963ES). Participants provided signed informed consent before study participation.

Study setting and participants

The methodology for this study has been described previously (Tumuhimbise and Musiimenta, 2021b and Tumuhimbise et al 2022). Briefly, the participants were recruited from three private for-profit hospitals in Mbarara city, in Southwestern Uganda. These facilities were purposively selected for having relatively large medical establishments with a large number of healthcare workers, being involved in TB case detection, and being at the center of handling a large number of outpatients in Mbarara city, which increases the likelihood of detection of presumptive TB cases. After performing symptom-based screening of patients for TB, all hospitals refer the presumptive TB patients to Mbarara Regional Referral Hospital (MRRH). The investigation involved in-depth interviews with purposefully selected healthcare workers from the study sites to understand how feasible and acceptable an mHealth intervention for enhancing public private mix for TB care is. Feasibility was assessed in terms of having access to internet, compatible phones and access to electricity for charging these phones. Healthcare workers were trained on how to use the application and were able to use it. All healthcare workers owned smartphones and were able to use the application for a period of one month (February 2022), and were asked to participate in phone-based interviews.

Study procedures

mHealth application (Tuuka app)

Tuuka application was developed based on mobile health (MOHE) framework, composed of six modules responsible for the functionality of the developed application.

Application layer module which offers an interface for an application to run on android platform
Service module responsible for sending and receiving of short message service reminders to presumptive Tuberculosis patients and healthcare workers
Network connection module responsible for the connectivity of the developed application to ensure that it functions
Storage module responsible for storage, access and retrieval of the patients’ data
Data processing module responsible for computing the time spent along the referral pathway
Data analytic module which enables the analysis and generation of reports from data collected on patients.

The application was developed following a user-centered design approach that involved input from the users (healthcare workers) during the development phase to understand the end user’s perspectives about the use of the app. Subsequent feedback was obtained from healthcare workers and refinements and redesigning of the application was carried out until the desired prototype was reached. The word Tuuka is a Luganda word meaning “reach” and was chosen to represent the referral context in which the application was implemented. The application was deployed on healthcare workers’ compatible low-cost smartphones from three private hospital facilities who referred patients to a public hospital MRRH TB clinic to enable the notification of the referred presumptive TB cases.

Tuuka Application implementation

Tuuka mobile application is built on a centralized patient management scenario to provide patient centered TB care that involves bringing together the parties involved in the patient’s pathway to effectively manage the patient where the private hospitals notify public hospitals about the referred presumptive TB patient. Tuuka is made up of two main components, the application server which is responsible for providing services to the users (Aldosery et al., 2021), and the client-side which provides an interface between the services provided by the system and the users. The application server is the back end of the developed application which responds to the requests and processes the received data and user authentications. The server is hosted by Linode with a cloud-based database for the storage of data. The application client is the front end that allows users (healthcare workers and the system administrators) to interact with the system. The application can be accessed through both the web interface (for accounts creation and report generation by system managers), and application interface for healthcare workers. Both the application and the web interface were developed using Kotlin programming language. The application is available on the google play store https://play.google.com/store/apps/details?id=ug.global.mohe and the web application on https://tuuka.tech/.

The main users of the Tuuka application are healthcare workers and its main functionality is capturing the referred patients’ data using built-in digital referral forms. The forms are designed to collect the same information collected through standard paper-based referral notes currently used by healthcare workers at private health facilities. Below are the procedures of Tuuka usability after the application installation.

The private healthcare worker enters the patients' details including names, telephone contacts, village, district, patient’s history, symptoms, treatment, and the referral notes.
The application automatically sends a SMS message to the patient’s mobile phone about the facility where they have been referred and also an SMS notification to a healthcare worker at the place of referral about the incoming patient. If affirmative, the patient goes to the referral unit. The application automatically records the exact time and date the patient was referred and seen at the public hospital to understand whether the patient is affirmative or not to the referral process.
Upon receiving a SMS notification about the incoming patient and receiving the patient at the facility, the public healthcare worker who already has an application installed notifies the private healthcare workers by saving the patients details and submitting the steps taken to handle the patient in terms of diagnosis, initiation on treatment.
In case a patient is not affirmative after 12 hours from the time of referral, the public health worker notifies him or her about going to the referral unit through an automatic SMS message.

Authentication and security

Both the mobile and web applications perform full encryption of databases, authentication and authorization. Users are required to authenticate themselves to access the information specific to them. Accounts are only created by the system administrator. The domain or connection to the server is through the Hypertext Transfer Protocol secure (HTTPS) which ensures that all communications are encrypted and Transport Layer Security (TLS) enforced at all times.

Data Collection

All study participants received the final version of the application from google play store and were trained on how to use the application (e.g, adding the referral in the app). Of the 24 participants who received the application, two reported failure to download the application from the shared link and were not available to participate in data collection. Twenty two participants who installed the application were contacted for a phone interview, and the interviewer-administered questionnaire to assess their overall experience with using the intervention. Acceptability and feasibility were determined quantitatively using the system usability scale (SUS) (Brooke 1996). The application would be considered acceptable if 90% of healthcare workers rate 70% (7/10) items on the SUS scale as “very good” or higher. Qualitatively, acceptability was assessed following the Unified Theory of Acceptance and Use of Technology (UTAUT) model (Venkatesh et al., 2003). UTAUT was used for it has been found a useful tool for assessing the likelihood of success for new technology and helps in understanding the factors for acceptance for proper designing of interventions (Venkatesh et al., 2003). Semi-structured interviews were carried out among 18 private healthcare workers and four public healthcare workers. The study participants’ experiences of using the application were assessed to document the acceptability and feasibility of the application through qualitative in-depth interviews. The data captured the perceived usefulness (performance expectancy) of the app, perceived ease of use (effort expectancy), social influence, and the facilitating conditions. A short survey was then administered to the participants to gather their social demographic details. In addition, a technology adoption survey based on the UTAUT constructs was administered to participants to elicit their experiences and challenges encountered while utilizing the app.

Data Analysis

Feasibility metrics and the quantitative assessment of acceptability were analyzed descriptively using STATA 13. The investigator used summary statistics to analyze the socio-demographic data. Interviews were recorded, transcribed, and analyzed using an inductive analysis approach based on the UTAUT model. In this approach, themes tailored to performance expectancy, effort expectancy, social influence, and facilitating conditions (Venkatesh et al., 2003) were developed from the collected data. A codebook was developed and reviewed for meaningful data extraction through an inductive and content analysis strategy (Neuendorf, 2017), a systematic process for interpreting textual data content through coding and category construction. Themes and subthemes were generated to describe different data patterns and category construction about the initial acceptability and feasibility of the developed application in TB care using content analysis. The review of transcripts guided the development of a coding scheme composed of various text sections that addressed the concepts of interest for example the perceived ease of use, influence from friends, workmates and the requirements to use the prototype by the private healthcare workers in following up TB patients on referral, were assigned descriptive codes. The elaboration and definitions for those illustrative codes and were categorized based on particular themes.

Social-demographic details of participants

Twenty-two healthcare workers including three medical doctors, fifteen nurses, three laboratory technicians and one pharmacist from three private hospitals and MRRH TB clinic participated in assessing the initial feasibility and acceptability of the developed mobile app. Healthcare workers were considered because they are the key users to interface with this application while patients receive SMS notifications triggered by the app, so the study capitalized on getting views of healthcare workers towards the application. The majority of the participants were female (n=16) and were nurses (n=15). Their median age was 28 years of age. All the three private hospital facilities that were part of this study refer presumptive TB cases to MRRH as indicated in Table 1.

Table 1: Participants’ demographics

Baseline characteristic	Participants
Baseline characteristic	N (%)
Median Age (IQR)	28 (25-29)
Gender
Female	16 (73)
Male	6 (27)
Marital status
Single	12 (54.5)
Married/partnered	10 (45.5)
Facility
Public Hospital	4 (18)
Private Hospital 1	8 (36)
Private Hospital 2	5 (23)
Private Hospital 3	5 (23)
Highest educational level
Certificate	7 (32)
Diploma	10 (45)
Degree	5 (23)
Designation
Nurse	15 (68)
Doctor	3 (14)
Lab Technician	3 (14)
Pharmacist	1 (4)
Number of years in general medical practice
1-5	12 (54)
>5	10 (46)

The potentials of Tuuka mobile application among healthcare workers

The majority of the participants reported that the application would help them make quicker medical decisions regarding the referred presumptive patient, enhance communication with other healthcare workers about the referred patients, enhance patient follow up and quick TB case notification, facilitate partnership between private and public hospital facilities and was perceived to be a quick and efficient referral system as shown in Table 2 below.

Table 2: The potentials of Tuuka mobile application among healthcare workers

Characteristic (N=22)	Agree	Strongly Agree
Helping me make quicker medical decisions	2	20
Help me communicate with other healthcare workers about the referred patient	1	21
Enhance patient follow up	1	21
Facilitate partnership with other health institutions	0	22
Quick TB case notification	1	21
Quick and efficient referral system	2	20

Acceptability and feasibility findings

The system usability scale (SUS) (Brooke, 1996) was used to explore how the healthcare workers perceived the usability of the application. The SUS is a 5 Likert scale for subjective assessment of system usability. The total mean for all respondents to the SUS score was 98 (SD 1.97) which according to Bangor et al., 2008 would be in the fourth quartile range in the acceptability range. The descriptive scores of responses to the 10 questions of the SUS are presented in Table 3 below.

Table 3: Tuuka usability findings based on the SUS

Characteristic (N=22)	Strongly Disagree	Disagree	Agree	Strongly Agree
I think that I would like to use Tuuka application frequently	0	0	5	17
I found the Tuuka application unnecessarily complex	22	0	0	0
I thought the Tuuka application was easy to use	0	0	3	19
I think that I would need the support of a technical person to be able to use this application	18	4	0	0
I found the various functions in this application were well integrated	0	0	0	22
I thought there was too much inconsistency in this application	19	3	0	0
I would imagine that most people would learn to use this application very quickly	0	0	4	18
I found the application very cumbersome to use	21	1	0	0
I felt very confident using the application	0	0	7	15
I needed to learn a lot of things before I could get going with this application	22	0	0	0

In addition to the SUS, the UTAUT model was utilized to explore how healthcare workers perceived the acceptability of the Tuuka mobile application. Questions were structured according to the four main constructs of the UTAUT model namely; performance expectancy, effort expectancy, social norms, and facilitating conditions. The application was found acceptable and the descriptive scores of responses are presented in Table 4 below.

Table 4: Perceived usefulness, ease of use and social norms of Tuuka Mobile application

Characteristic (N=22)	Neither	Agree	Strongly Agree
Tuuka mobile application is useful in following up the referred presumptive TB patients	0	7	15
Tuuka mobile application is more useful than the current referral procedures	0	6	16
Tuuka mobile application positively affected the way I feel about referring presumptive TB patients	0	5	17
Tuuka mobile application would help me in following up the referred patients in time	0	5	17
Tuuka mobile application makes it easier to follow up referred patients	2	5	16
Perceived ease of use of Tuuka mobile app
It would be easy for me to use Tuuka mobile application to refer patients	0	4	18
It would easy for me to remember to use Tuuka mobile application	0	4	18
It was easy for me to install Tuuka mobile application	0	5	17
Social norms about using Tuuka
People think I should use Tuuka mobile application to refer patients	0	6	16
My friends, workmates think I should use Tuuka mobile application to refer patients	0	0	22

Facilitating Conditions for Tuuka mobile application

All participants had smartphones for Tuuka application to be installed, had electricity and cellular network as facilitating factors to the usage of the application.

Qualitative findings

The intervention acceptability results are presented following the UTAUT model (Figure 1) and detail the performance, effort expectancy, social norms, and facilitating conditions associated with the mobile app.

Performance Expectancy

The study participants found Tuuka mobile application useful in notifying both patients to go to the place of referral and the public healthcare workers about the referred patients. They described that the SMS notifications triggered by the Tuuka mobile application at the private health facility remind and force patients to go the place of referral and also enables the healthcare worker at the public health facility to prepare to receive the referred patient.

The application notifies the healthcare worker at the public hospital that a certain patient has been referred from a private hospital and also notifies the patient to go to the place of referral. So if the patient receives this message, he or she will be forced and reminded to go to the hospital where he has been referred. (Female, Nurse, 38 years, Public Hospital).

Tuuka mobile application was reported to enhance communication between facilities. The application was reported to allow healthcare workers at both the private and public health facilities to communicate with each other about the referred patient after receiving an SMS notification which would help to ascertain whether the patient reached the place of the referral or not.

When a healthcare worker at the private hospital refers a patient, and healthcare worker at the place of referral receives a notification about the referred patient and can immediately reply in the application which brings that easy communication across facilities. (Male, Lab technician, 46 years, Private Hospital).

The mobile application was reported to enhance patient-centered care through coordinated patient follow up efforts in both the private and public hospitals by ensuring privacy and confidentiality of patients where they can easily be worked on without lining up since the healthcare workers are made aware in advance about the referred patient.

This application links the referred patients by alerting the public hospitals about their coming and they can be worked on faster by the healthcare workers upon reaching the facility. This makes a patient feel good knowing that he or she is being cared for. (Female, Nurse, 25 years, Private Hospital).

Effort Expectancy

Following the healthcare workers’ initial orientation to use the application, they found it easy to use for referring the presumptive TB cases. The application has an SMS functionality that would notify the healthcare worker at the public facility about the referred patient which would prompt them to do the needful irrespective of where they are.

I think the application does not need a lot of time to operate, it’s just a matter of adding the patients’ details and the public hospital gets notified about the referred patient. (Female, Nurse, 25 years, Private Hospital).

The participants at the referral unit noted that the application functioned well as evidenced by receiving SMS notifications about an incoming patient as soon as the private healthcare worker referred the patient.

The application was working very well because immediately when a patient was referred from the private hospital, I would receive the message on my phone about the incoming patient. (Female, Nurse, 38 years, Public Hospital).

Social Influence

Participants reported positive perception about the intervention by other hospital staff which increases their chances of utilizing the application.

My fellow healthcare workers don’t have any problem with me using the app, actually they feel it’s important in linking up the referred patients. (Female, Nurse, 26 years, Private Hospital).

Facilitating Conditions

Participants noted that the application does not require a lot of space for installation and the internet to be downloaded which was perceived to enhance its acceptability. They reported being repulsive to downloading apps that require a lot of space and internet as it would be expensive in terms of buying internet packages in the long run.

The application didn’t take a lot of internet bundles to download, and, it doesn’t take a lot of storage space on my phone. (Male, Medical Doctor, 26 years, Public Hospital).

However, participants noted that the internet might limit the usability of the application since the application entirely runs on the internet. The SMS notifications sent to healthcare workers were perceived to force the healthcare worker to buy internet and get more information about the patient

You need internet so that every time you receive the SMS notification about the referred patients, you login to see the details about the referred patient. But in case one doesn’t have internet, the SMS notification will still come, one can buy internet bundles and log in the application. (Female, Nurse, 38 years, Public Hospital).

Participants also complained about the lack of time to utilize the application due to the busy schedules in terms of high number of patients to be worked and at times they would forget about the app

I personally would be overwhelmed with meeting patients on ward and by the time I remember using the application it would be too late. (Female, Nurse, 28 years, Private Hospital).

In this paper, a mobile application called Tuuka was developed to enhance the following up of presumptive TB patients referred from private to public hospitals in Southwestern Uganda. Healthcare workers reported that the application would help them make quicker medical decisions regarding the referred patients, enhance communication with other healthcare workers, and patient follow up. Drawing from the UTAUT model, it was found out that a mobile health application can be an acceptable and a feasible tool for following up referred patients from private to public hospitals among healthcare workers. The main construct to the acceptability of the application was perceived usefulness where the developed mobile application was reported to not only have potential to remind the referred presumptive patients to go to the place of referral but also notify healthcare workers at the public health facility about the incoming referred patient which facilitates the communication across facilities and enhances patient based care.

Our findings reveal that notifying healthcare workers at the place of referral about the referred patients was interpreted as caring for the referred patients which would motivate them to adhere to the referral knowing that healthcare workers at the place of referral are waiting for them. Ensuring the proper notification, referral and followup across facilities is an important facet for continuity of care among Tuberculosis patients (Marias, Kallon, Dudley, 2019) and improves care coordination (Moore et al., 2012). Lack of these proper mechanisms for communication regarding the referred patients may compromise the continuity of treatment (WHO, 2010). SMS reminders’ implication for care for patients has been also reported by (Ware et al., 2016) among people living with HIV in rural Southwestern Uganda. The findings are in tandem with several literature reviews that have highlighted how SMS reminders can aid in reducing missed hospital appointments (Opon et al., 2020) and assist patients to adhere to their regimen to reduce the rates of readmission (Perri-Moore et al., 2016). Therefore the utilization of a mobile application that automatically sends reminders to patients and notifications to healthcare workers about the referred may enhance continuity of care among patients.

The SMS reminders component of the mobile application triggered at the private hospital may enhance timely care offered to patients thus reducing delays along the referral pathway. However receiving a message about the referred patient among healthcare workers at the referral unit may not guarantee that the patient will be received, there could be other factors that may result in non-response from healthcare worker like shortage of healthcare workers which affects the delivery of healthcare services (Baine and Kasangaki, 2014), high doctor- patient ratio, in Uganda, the doctor patient ratio is 1:25,000 (Mwesigwa, Lule and Nakabugo, 2017) which is way below the recommended WHO doctor-patient ratio of 1:1000. The referred patients may be hindered from reaching the place of referral like lack of transport as noted by (Tumuhimbise et al., 2020), being too weak to reach the facility. Therefore the implementers of mHealth interventions that utilize SMS should bear in mind that other factors may affect adherence to the referral even after receiving the intervention.

The application was also reported to enable communication between both private and public hospitals which helps in keeping track of the stage where the referred patient has reached. This ensures concerted efforts from both public and private facilities to ensure that they are engaged in TB care efforts. In a setting where most private hospitals are not accredited to provide TB services, and where healthcare workers of these hospitals refer their presumptive patients to public health facilities, the application offers a follow-up mechanism for ensuring that the public hospitals are notified about each case identified in these private hospitals. Thus enhancing PPM through garnering efforts from both actors in ensuring that the patient has been followed up to ensure they are not lost along the referral pathway which is key in ensuring continuity of care for patients, fosters evidence based TB care per the international standards (WHO, 2015).

Lack of access to the internet by healthcare workers was also noted as a potential limiting factor for the usability of the Tuuka application. In settings like Uganda where internet penetration is still low, and healthcare workers have to buy their own internet bundles to use the app, which may not be sustainable in the long run. The study findings have shown that mobile apps that require more internet bundles to be downloaded and consume a lot of space on the users' devices are likely not to be utilized. Users are likely to abandon mobile applications that take up a lot of space or memory on their phones (Dennison et al., 2013). Therefore developers should put this into consideration.

There were no challenges with user motivation reported in this study probably due to the limited amount of time the intervention was used. However, the busy working nature of healthcare workers coupled with the prevailing high patient-doctor ratio may constrain the use of the app. Most mobile health interventions lack sustained use and are later abandoned by the intended users mainly due to lack of motivation or declining interest to use the intended intervention(Mustafa et al 2022). Future studies can explore the possible ways of motivating staff (especially at the private facility) to use the app.

Implications for policy and implementation

This study implies that the designing of mHealth interventions for healthcare workers should be done with caution due to the nature of their work. Therefore the integration of these interventions in the routine work of healthcare workers needs to be carefully planned if the required results are to be achieved. Secondly, the underlying technological development used to develop the application can be expanded in following up all patients referred from private to public hospitals. The application enables the automation of the referral process especially in settings where public-private referrals are common and offers valuable insights and knowledge necessary for the development of a similar intervention in other settings.

Limitations of the study

A purposive sampling approach for recruiting the respondents was utilized, which has the potential for selection bias. In addition, although this study recruited all healthcare workers that fitted the selection criteria, (experience in TB-related case identification, referral and treatment), the sample size was small which limits the ability for generalizing the study findings among the healthcare workers in similar settings. This study was conducted in an urban setting; these findings may not be generalizable in other settings like rural areas, where there might be considerable differences in implementation and practices. Importantly, this study didn’t assess patients’ perceptions towards the app. This was because the key users to interface (install) with this application are healthcare workers while patients receive SMS notifications triggered by the app, so the study capitalized on getting views of healthcare workers towards the application.

This study showed that the Tuuka mHealth application for private hospitals to notify public hospitals about the referred presumptive TB patients is acceptable and feasible for following up the referred presumptive TB patients referred from private to public hospitals in southwestern Uganda. The key aspects to intervention acceptability and feasibility was performance expectancy in terms of notifying healthcare workers at the public hospital about the incoming referred patient and facilitating communication across facilities thus enhanced patient based care. Future efforts can explore the possible ways of motivating staff (especially at the private facility) to use the app.

Declaration of Interest

The authors declare that they have no conflict of interests.

Acknowledgments

This research is part of the PhD research carried out by Wilson Tumuhimbise the first author and is supervised by Drs. Angella Musiimenta, Fred Kaggwa and Daniel Atwine in the Faculty of Computing and Informatics at Mbarara University of Science and Technology (MUST), Mbarara, Uganda. The supervisors per the requirements of doctoral studies at MUST reviewed the proposal, codebook for correctness and had no relationship with the participants. The participants (healthcare workers) were purposively selected from the participating hospitals because of their involvement in TB care at the study sites and had no mutual relationship with the research team. Dr. Musiimenta is also supported by the Fogarty International Center of the National Institutes of Health under Award number K43TW010388-05S1, and the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number R21HD107985, and the Federal German Ministry of Education and Research (01DG21014). I would like to acknowledge Associate Professor Luke Davis (Yale School of Medicine) for the support in conceptualizing the research idea.

Funding

Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number R21HD107985. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ALDOSERY, A., MUSAH, A., BIRJOVANU, G., MORENO, G., BOSCOR, A., DUTRA, L., SANTOS, G., NUNES, V., OLIVEIRA, R. & AMBRIZZI, T. 2021. MEWAR: Development of a Cross-Platform Mobile Application and Web Dashboard System for Real-Time Mosquito Surveillance in Northeast Brazil. Frontiers in public health, 9.
ALI, S. M., POWERS, R., BEORSE, J., NOOR, A., NAUREEN, F., ANJUM, N., ISHAQ, M., AAMIR, J. & ANDERSON, R. 2016a. ODK scan: digitizing data collection and impacting data management processes in Pakistan's tuberculosis control program.. Futur. Internet, 8
ANAND, T., BABU, R., JACOB, A. G., SAGILI, K. & CHADHA, S. S. 2017. Enhancing the role of private practitioners in tuberculosis prevention and care activities in India. Lung India: Official Organ of Indian Chest Society, 34, 538.
ASUQUO, A. E., POKAM, B. D. T., IBENEME, E., EKPEREONNE, E., OBOT, V. & ASUQUO, P. 2015. A public–private partnership to reduce tuberculosis burden in Akwa Ibom State, Nigeria. International journal of mycobacteriology, 4, 143–150.
Baine, S.O. and Kasangaki, A., 2014. A scoping study on task shifting; the case of Uganda. BMC health services research, 14(1), pp.1–11.
BANGOR, A., KORTUM, P. T. & MILLER, J. T. 2008. An empirical evaluation of the system usability scale. Intl. Journal of Human–Computer Interaction, 24, 574–594.
BROOKE, J. 1996a. Sus: a “quick and dirty’usability. Usability evaluation in industry, 189.
CHOUN, K., ACHANTA, S., NAIK, B., TRIPATHY, J. P., THAI, S., LORENT, N., KHUN, K. E., VAN GRIENSVEN, J., KUMAR, A. & ZACHARIAH, R. 2017a. Using mobile phones to ensure that referred tuberculosis patients reach their treatment facilities: a call that makes a difference. BMC Health Services Research, 17, 1–7.
DENNISON, L., MORRISON, L., CONWAY, G. & YARDLEY, L. 2013. Opportunities and challenges for smartphone applications in supporting health behavior change: qualitative study. Journal of medical Internet research, 15, e2583.
DEWAN, P. K., LAL, S., LONNROTH, K., WARES, F., UPLEKAR, M., SAHU, S., GRANICH, R. & CHAUHAN, L. S. 2006. Improving tuberculosis control through public-private collaboration in India: literature review. Bmj, 332, 574–578.
LAW, S., PIATEK, A. S., VINCENT, C., OXLADE, O. & MENZIES, D. 2017. Emergence of drug resistance in patients with tuberculosis cared for by the Indian health-care system: a dynamic modelling study. The Lancet Public Health, 2, e47-e55.
LESTARI, B. W., ARISANTI, N., SIREGAR, A. Y., SIHALOHO, E. D., BUDIMAN, G., HILL, P. C., ALISJAHBANA, B. & MCALLISTER, S. 2017. Feasibility study of strengthening the public–private partnership for tuberculosis case detection in Bandung City, Indonesia. BMC research notes, 10, 1–6.
LESTARI, B. W., ARISANTI, N., SIREGAR, A. Y., SIHALOHO, E. D., BUDIMAN, G., HILL, P. C., ALISJAHBANA, B. & MCALLISTER, S. 2017. Feasibility study of strengthening the public–private partnership for tuberculosis case detection in Bandung City, Indonesia. BMC research notes, 10, 1–6.
Marias F, Kallon II, Dudley L. 2019. Continuity of care for TB patients at a South African hospital: a qualitative participatory study of the experiences of hospital staff. PLoS One. 14(9):e0222421.
Moore, T., Shapiro, J.S., Doles, L., Calman, N., Camhi, E., Check, T., Onyile, A. and Kuperman, G., 2012. Event detection: a clinical notification service on a health information exchange platform. In AMIA Annual Symposium Proceedings (Vol. 2012, p. 635). American Medical Informatics Association.
MUSIIMENTA, A., ATUKUNDA, E. C., TUMUHIMBISE, W., PISARSKI, E. E., TAM, M., WYATT, M. A., WARE, N. C. & HABERER, J. E. 2018b. Acceptability and feasibility of real-time antiretroviral therapy adherence interventions in rural Uganda: mixed-method pilot randomized controlled trial. JMIR mHealth and uHealth, 6, e122.
MUSIIMENTA, A., TUMUHIMBISE, W., MUGABA, A. T., MUZOORA, C., ARMSTRONG-HOUGH, M., BANGSBERG, D., DAVIS, J. L. & HABERER, J. E. 2019. Digital monitoring technologies could enhance tuberculosis medication adherence in Uganda: Mixed methods study. Journal of clinical tuberculosis and other mycobacterial diseases, 17, 100119.
MUSTAFA, A. S., ALI, N. A., DHILLON, J. S., ALKAWSI, G. & BAASHAR, Y. User Engagement and Abandonment of mHealth: A Cross-Sectional Survey. Healthcare, 2022. Multidisciplinary Digital Publishing Institute, 221.
Mwesigwa A, Lule BB, Nakabugo Z. Cost of sacking 1,000 doctors. The Observer, 2017. Available: https://observer.ug/news/headlines/56053-cost-of-sacking-1-000-doctors.html. Accessed: 21 July 2022.
NEUENDORF, K. A. 2017. The content analysis guidebook, sage.
O’HANLON, B., NAKYANZI, A., MUSEMBI, V., BUSULWA, I., HUSBAND, R., OKUMU, R. & KANNEGANTI, S. 2017. Exploring partnership opportunities to achieve universal health access: 2016 Uganda Private Sector Assessment in Health.
OPON, S. O., TENAMBERGEN, W. M. & NJOROGE, K. M. 2020. The effect of patient reminders in reducing missed appointment in medical settings: a systematic review.
PANDE, T., SARAVU, K., TEMESGEN, Z., SEYOUM, A., RAI, S., RAO, R., MAHADEV, D., PAI, M. & GAGNON, M.-P. 2017a. Evaluating clinicians’ user experience and acceptability of LearnTB, a smartphone application for tuberculosis in India. Mhealth, 3.
PERRI-MOORE, S., KAPSANDOY, S., DOYON, K., HILL, B., ARCHER, M., SHANE-MCWHORTER, L., BRAY, B. E. & ZENG-TREITLER, Q. 2016. Automated alerts and reminders targeting patients: a review of the literature. Patient education and counseling, 99, 953–959.
SHANI, R. & OMER, F. 2021. The Uninstall Threat: 2020 App Uninstall Benchmarks 2021 [Online]. Berlin, Germany: AppsFlyer Ltd. Available: https://www.appsflyer.com/resources/reports/app-uninstall-benchmarks/ [Accessed 3rd March 2022].
TUMUHIMBISE, W. & MUSIIMENTA, A. 2021a. Barriers and Motivators of Private Hospitals’ Engagement in Tuberculosis Care in Uganda. Global Implementation Research and Applications, 1, 279–290.
TUMUHIMBISE, W., ATWINE, D., KAGGWA, F. AND MUSIIMENTA, A., 2022. Enhancing Tuberculosis Care in Southwestern Uganda: Facilitators and Barriers to Utilizing Mobile Health Technologies. Global Implementation Research and Applications, In press.
TUMUHIMBISE, W. & MUSIIMENTA, A. 2021b. A review of mobile health interventions for public private mix in tuberculosis care. Internet Interventions, 100417.
TUMUHIMBISE, W., ATUKUNDA, E. C., AYEBAZA, S., KATUSIIME, J., MUGYENYI, G., PINKWART, N. & MUSIIMENTA, A. 2020. Maternal health-related barriers and the potentials of mobile health technologies: qualitative findings from a pilot randomized controlled trial in rural southwestern Uganda. Journal of family medicine and primary care, 9, 3657.
UCC 2021. Uganda Communications Communication. Market Perfomance Report 2Q21. In: COMMUNICATION, U. C. (ed.).
UPLEKAR, M. 2003. Involving private health care providers in delivery of TB care: global strategy. Tuberculosis, 83, 156–164.
VAN DER KOP, M. L., MEMETOVIC, J., SMILLIE, K., COLEMAN, J., HAJEK, J., NATASHA VAN BOREK, M., TAYLOR, D., ALASALY, K., JOHNSTON, J. & LESTER, R. T. 2013. Use of the WelTel mobile health intervention at a tuberculosis clinic in British Columbia: a pilot study. Journal of Mobile Technology in Medicine, 2, 7–14.
VENKATESH, V., MORRIS, M. G., DAVIS, G. B. & DAVIS, F. D. 2003. User acceptance of information technology: Toward a unified view. MIS quarterly, 425–478.
WARE, N. C., PISARSKI, E. E., TAM, M., WYATT, M. A., ATUKUNDA, E., MUSIIMENTA, A., BANGSBERG, D. R. & HABERER, J. E. 2016. The Meanings in the messages: how SMS reminders and real-time adherence monitoring improve antiretroviral therapy adherence in rural Uganda. AIDS (London, England), 30, 1287.
WEI, Y., ZHENG, P., DENG, H., WANG, X., LI, X. & FU, H. 2020. Design features for improving mobile health intervention user engagement: systematic review and thematic analysis. Journal of medical Internet research, 22, e21687.
WHO 2018b. Public–private mix for TB prevention and care: a roadmap. Geneva: World Health Organization.
WHO 2020. Tuberculosis profile: Uganda [Online]. Available: https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22country%22&lan=%22EN%22&iso2=%22UG%22 [Accessed 19th April 2022].
WHO 2021. Global Tuberculosis Report 2021. Geneva, Switzerland: World Health Organization.
WHO 2015a. Implementing the end TB strategy: the essentials (No. WHO/HTM/TB/2015.31). World Health Organization.
WHO, 2015b. Tuberculosis: Public-private mix (PPM) for TB care and control. World Health Organization. Available: https://www.who.int/news-room/questions-and-answers/item/public-private-mix-ppm-for-tb-care-and-control
World Health Organisation. Global TB control. Geneva: WHO; 2010. Available from: http://apps.who.int/iris/bitstream/10665/44425/1/9789241564069_eng.pdf
WOOD, R., JOHNSTONE-ROBERTSON, S., UYS, P., HARGROVE, J., MIDDELKOOP, K., LAWN, S. D. & BEKKER, L.-G. 2010. Tuberculosis transmission to young children in a South African community: modeling household and community infection risks. Clinical infectious diseases, 51, 401–408.
ZHOU, Y., LU, Y., NI, Y., WU, D., HE, X., ONG, J. J., TUCKER, J. D., SYLVIA, S. Y., JING, F. & LI, X. 2022. Monetary incentives and peer referral in promoting secondary distribution of HIV self-testing among men who have sex with men in China: A randomized controlled trial. PLoS medicine, 19, e1003928.

No competing interests reported.

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Editorial decision: Major revision
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Acceptability and Feasibility of a Mobile Health Application for Enhancing Public Private Mix for TB care among Healthcare workers in Southwestern Uganda

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Abstract

Figures

Introduction

Methodology

Ethical Approval

Study setting and participants

Study procedures

mHealth application (Tuuka app)

Tuuka Application implementation

Authentication and security

Data Collection

Data Analysis

Results

Social-demographic details of participants

The potentials of Tuuka mobile application among healthcare workers

Acceptability and feasibility findings

Facilitating Conditions for Tuuka mobile application

Qualitative findings

Performance Expectancy

Effort Expectancy

Social Influence

Facilitating Conditions

Discussion

Implications for policy and implementation

Limitations of the study

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1