Characteristics of study participants
In this study, fifteen eligible participants responded to the interview. The age of the participants ranged from 21 to 45 years. Among study participants, nine were males and six were females. Six of them were urban and nine of them were residents. Two participants were attending their treatment at hospitals and thirteen at the health centres. Regarding educational status, twelve participants had a formal education of different levels and three participants with no education at all (Table 2).
The study established three main themes including feasibility, acceptability and implementation challenges of mobile phone-based reminder systems for TB treatment support during continuation phase.
Feasibility of the reminder system
The local telecommunication (Ethio-telecom) corporation was willing, cooperative and their system was compatible to support the implementation of a phone-based medication reminder system. We also realized the engagement of participants who could not read text messages via the enclosure of graphic messages in the package and providing a five minutes hands-on training during enrolment individually to familiarize them with accessing and understanding the messages. The training process followed: informing the purpose, showed how to operate the messages. After enrolment, a welcoming messages were sent for patients in intervention group for testing and motivating patient’s engagement before commencement of actual reminder messaging.
Overall, from the total expected reminder messages sent out to the participants, 84.6% of them were delivered to the participants. The report from the local telecom database indicated that 4 of 152 participants did not receive reminder messages at all. Regarding access to reminder messages, the majority of the participants received both daily and weekly reminder messages almost every day for the four months of continuation phase. One of the participants responded to the question “how frequently received the reminder messages?” that:
“I received the medication reminder message almost every day and every week for the refilling…, P15, Female TB patient
On the other hand, few participants reported inconsistent delivery of the reminder messages.
“…last week, I received all messages continuously, but this week, I received only two messages…” P04, Male TB patient
All who received the reminder messages replied that they can easily open and see the messages. All participants differentiated and understood the daily medication and weekly pill refilling reminders.
Another participant replied to the question “how easy to open and understand the messages?”
“… opening the message was not difficult for me, I sometimes opened and saw, but always see the notification without opening, and I realized that messages were all the same.” P05, Female TB patient
Acceptability of the reminder system
All participants that received the reminder messages replied as the system was useful and satisfied their expectations. Many of the participants suggested the system for wider scale-up. Some of the participants were texting and some calling back our system to acknowledge the reminder services providers, even though, we had informed them during enrolment into the intervention that the system was a one-way that had no display for incoming messages from the participants. The telecom generated call-details data also shown that many participants were texting back to our system, even if, we had informed them not required to SMS back to the system during participant enrolment. One of the participants replied to the question “how satisfied with the benefit of the reminder system?”:
“I’ [participant] was happy with the reminder messaging that had supported me a lot, sometimes I text back to you saying thank you…” P04, Male TB patient
Another participant was also added that:
“I frequently tried a phone call back to you [the reminder system’s number] but not working, I wanted to thank you for the support. I also wish others [other patients] to use the system.” P07, Female TB patient
One participant mentioned that the intervention package was not comprehensive enough to fully engage patients in their treatment. It focused only on reminding pills and suggested including other TB treatment-related components like nutritional, drug side effect and precaution, related Lab tests, awareness creation and motivational messages.
“The system was helpful…, but it [reminder system] was focused only on reminding pills. It would have been good, if you also include other related messages e.g. nutritional messages and others (could be drug side effect and precaution, related laboratory test, awareness about the disease and motivational messages)” P02, Male TB patient
We asked participants whether they were bored with reminder messages. All except one participant replied that the system was not boring.
“…it’s like reminding to take your breakfast, I never bored of the reminder messages.” P04, Male TB patient
On the other hand, one of the participants mentioned that receiving daily reminder messages for long period could create unpleasant moods in the patients.
“I agree with the benefit particularly for those who may forget their pills. I was also receiving the messages, but after a while, I feel bored and switched off the notification because I don’t need it [reminder message]. I’m strict with my pills and my wife also supported me.” P14, Male TB patient
Challenges related to implementation of the reminder system
Throughout the implementation of the new intervention, we identified major challenges like system interruption doubting fraud, cost of intervention, failure of message delivery and individual differences with convenient time of sending messages.
The reminder system was interrupted for four days in the middle of implementation doubting fraud during the national curfew related to political unrest. We investigated that the reminder system was suspected of fraud due to bulky messages sent out from a single subscriber. The problem was sorted out with official communications. The local telecom experts suggested corporate SIM cards than personal-subscribed lines to reduce risk of system interruption. One of the four participants who did not receive messages at all reported a technical problem (damage) of mobile devices as a reason for failure to receive messages. Failure of message delivery was also among the major challenges. Few reported that they had lack and/or fluctuating electric power and poor telecommunication network connections were not stable in the area.
“…last week, I received all messages, but this week, I received only two messages. Our electric power and mobile network was not stable, if that could be the possible reasons for missing your reminder messages” P04, Male TB patient
Regarding time of message delivery, many participants were convenient to receive the daily medication reminder message 30 minutes before 8:00 AM (conventional time of TB medication) and a day before the due date of clinic appointment for pill refilling. One participant responded to the question “How convenient with the time of delivery of reminder messages to take daily medication and weekly refilling pills on time?”
“I received the messages 30 minutes before taking my pills but the weekly reminder was not consistent with my scheduled date of appointment. Otherwise, the time for daily medication reminder and even the weekly reminder, if correctly scheduled [consistent with the actual date of appointment], both would be a convenient time for me and I guess appropriate for others too” P04, Male TB patient
However, a considerably large number of participants received the reminder message after taking pills. It indicates that this particular group of participants used to take their pills before 8:00 AM (the prescribed time of medication). One of those participants responded that:
“…messages often delivered late. Due to the nature of my work, I used to take my pills very early at 6 AM, however, the messages often delivered at 7:30 AM, however, I’m carefully following my pills and with full support from family.” P11, Male TB patient
According to the current Ethio-telecom tariff, the cost of the intervention was 15.00 Ethiopian Birr equivalent (rate of exchange during implementation) to 0.43 USD to deliver 136 messages per individual patient to complete the four monthly continuation treatment phase. The TB treatment service has been nationally provided for free of charge.