Author: Zekariyas Sahile Nezenega
Nezenega, Zekariyas Sahile, 2024 Mobile-assisted medication adherence support intervention for Tuberculosis patients: Effectiveness, experiences and adoption intention, Flinders University, College of Nursing and Health Sciences
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Tuberculosis (TB) control programs face serious challenges in resource-limited settings, particularly in Ethiopia, where 20% of TB patients do not adhere to prescribed TB medication. Mobile phone-based adherence interventions can address challenges associated with non-adherence to TB medication because they allow direct communication between providers and patients. However, there is conflicting evidence regarding the efficacy of SMS text message interventions on TB medication adherence. Additionally, most adherence interventions based on mobile phone messaging are not tailored to the local context and needs of the target audience.
A pragmatic mixed-methods evaluation design was employed to systematically develop and evaluate the Mobile-assisted medication adherence support (Ma-MAS) intervention in Addis Ababa, Ethiopia. The Medical Research Council (MRC) framework including the information-motivation-behavioural skills (IMB) model and behavioural change techniques, was employed to develop and validate the Ma-MAS intervention. The feasibility and acceptability of the intended intervention were assessed by a cross-sectional survey. A parallel-group randomised control trial design was used to evaluate the effectiveness of Ma-MAS intervention among a sample of randomly assigned (n=186) participants. Participants in the Ma-MAS group received a daily SMS text message and a weekly phone call regarding their daily medication intake and reminders to attend clinic visits for eight weeks. Participants in the control group did not receive SMS texts or phone calls but received the same routine standard care as the Ma-MAS group. The primary outcome was the proportion of adherence measured by urine tests for isoniazid (INH) metabolites at the end of the fourth and eighth week of follow-up period. A post intervention interpretive study with qualitative descriptive approach and quantitative cross-sectional survey were also employed to inform the study findings on utility and acceptability.
In total, 40 SMS text messages were selected by experts to use for TB medication adherence based on content validity indexes above 0.80. According to a cross-sectional study, 88.5% of TB patients have their own mobile phone, and 93.5% of mobile phone owners were willing to receive SMS text message as reminders for medication intake and 92% were willing to receive SMS text message as reminder for clinic appointments. Most participants were also willing to receive phone calls as reminders for medication intake (91%) and clinic appointments (93%).
In the experimental study, Ma-MAS significantly improved adherence to TB medications by 15.25% (95%CI: 5.38, 25.12; P-value=0.0065) after eight weeks of the intervention compared to the standard care alone in the control group. At the end of the eight weeks follow-up period, the predicted probability of adherence to TB medication in the Ma-MAS group was 86% (95%CI: 81, 93), and in the control group was 70% (95%CI: 61, 79). Ma-MAS also improved adherence to TB medication by 15.30% (95%CI: 6.68, 23.90; P-value=0.0022) after four weeks of the intervention compared to the control group. Ma-MAS intervention was shown to be useful to improve TB medication adherence as measured by a urine test for isoniazid (INH) metabolites. The Ma-MAS intervention had high acceptance and is a useful for reminder of TB medication, habit formation, awareness creation, motivation, enhancement of perceived professional care, and health consultation. This study therefore provides evidence for the effectiveness of mobile-assisted approaches to medication adherence through a rigorously planned and executed randomised control trial and interpretive study in a particular setting where best practice in medication adherence is critical to health outcomes but difficult to achieve by conventional approaches.
Keywords: Tuberculosis medication adherence, digital health intervention, mobile health intervention, SMS text messages, phone calls, Ethiopia
Subject: Public Health thesis
Thesis type: Doctor of Philosophy
Completed: 2024
School: College of Nursing and Health Sciences
Supervisor: Professor Paul Arbon