Background
Methods
Study setting and design
Characteristics of the home-based mHealth intervention and SMS messages
Sex | Age | Education | Occupation | Individual Income | Type of SMS Received | Action Requested of Household Contact | Action Taken By Household Contact | Quotation |
---|---|---|---|---|---|---|---|---|
Female | 18 | Secondary | Student | 0 UGX | Unlikely TB | Reply HELP if you do not get better | None | My parent showed me the message and I was happy that I did not have TB |
Female | 19 | Secondary | Student | 0 UGX | Unlikely TB | Reply HELP if you do not get better | None | My mother told me and I asked her to see the message and felt good |
Female | 22 | Primary | Unemployed | 0 UGX | Unlikely TB | Reply HELP if you do not get better | Waited for the LHW to come for a follow-up visit | Well, it is okay if she wants to send through a message, I will still wait for her to come and I ask her |
Female | 22 | Secondary | Unemployed | 0 UGX | Unlikely TBb | Reply HELP if you do not get better | None | I just felt happy because I wanted to know the actual diagnosis. |
Female | 40 | Primary | Self-employed | 50,000 UGX | Unlikely TB | Reply HELP if you do not get better | None | I got relieved and provided support to the patient |
Female | 61 | Primary | Unemployed | 0 UGX | Unlikely TB | Reply HELP if you do not get better | Waited for the LHW to come for a follow-up visit | I was happy but also wanted to talk to her the next time she visits |
Male | 19 | Secondary | Unemployed | 0 UGX | Unlikely TB | Reply HELP if you do not get better | Sent “HELP” | On that day it was sent to me I replied with HELP to it because I felt the testing machine might have had an error |
Male | 29 | Tertiary | Self-employed | 1,000,000 UGX | Unlikely TB | Reply HELP if you do not get better | Visited a clinic at a later date | …I expect to go to South Africa for about 3 months and we were advised to go for a check-up for TB and HIV and the results were needed and that is why I had to go for that test. |
Male | 37 | Secondary | Self-employed | 350,000 UGX | Confirmed TBa | Visit a health centre for treatment | Telephoned the LHW to schedule an appointment | I immediately contacted the LHW, I called her and we scheduled the appointment the next morning |
Male | 39 | Tertiary | Self-employed | 800,000 UGX | Unlikely TB | Reply HELP if you do not get better | Waited for TB longitudinal message | I waited for a second message but it hasn’t come through |
Study population, sampling, and recruitment
Procedures
Analysis
Protection of human subjects
Results
Characteristics of participants
Household contacts’ experiences before and after receiving TB test results
Anxiety about a possible diagnosis of TB prior to receiving the SMS results
The TB education that household contacts received from LHWs during household contact investigation increased their concerns about TB. Most indicated that the perceived consequences of the test results contributed to their anxiety:“Now, since you have some signs showing that you have TB and you are very eager to know whether these signs are of TB… Now, do I have TB or I don’t have? You can be so anxious to know…What are the results?” [Female, 18 years]
Most household contacts who reported anxiety also said that, during the time between the household contact investigation visit and receipt of their test results via SMS, they believed they had TB infection and urgently wished to confirm their status.“The question I had: ‘If the results come out and show that I am infected, what will I do?’ You know, I fear taking tablets so much and I kept asking myself what I will do and where to start from. My husband had explained to me that in case I don’t take the medicine well then I might be put on injections and whenever I looked at my child I felt she is still young that needs my support and I had made up my mind to take the medication in case I am found positive.” [Female, 22 years]
Relief upon confirming TB status
Notably, the respondent who received an SMS confirming a positive diagnosis for his young daughter also described a sense of relief. When he received the result via SMS he explained:“You know, the tension I had knowing that my sister is infected… I thought that even the rest of us at home might be infected with the same disease. It helped me. In fact, the time the message came in I was doing my work that side of Mubende. It came at the time I didn’t expect it, it was just like the same way any normal message would come in, you might not be aware of what has come through. I later opened the message and it was indicating that I was TB-negative, and I felt relieved of that burden that I had on mind.” [Male, 29 years]
For this respondent, even a positive TB result provided relief because it ended prolonged uncertainty over the source of the illness. However, several household contacts who received negative TB results via SMS said that, while they felt relief, they also desired further evaluation for their ongoing symptoms in order to confirm a specific diagnosis and obtain appropriate treatment.“At that time, I felt so relieved. I had spent time buying different types of medicine but the child would still continue coughing. On that day I felt relieved because I knew I had come to the right diagnosis of the illness. I got to know the type of medication required and the disease she is suffering from.” [Male, 37 years]
Ambivalence about SMS as a medium for communicating test results
On the other hand, the same household contacts who praised the convenience of SMS also said that they remained concerned about their TB status even after receiving the test results via SMS because they were not fully confident that the results were accurate. They cited a belief that new technologies may be error-prone as an explanation of their uncertainty about their SMS-delivered results. Some reported a preference for face-to-face delivery of results:“…it was easier for me because I had my phone and at any time unexpectedly you receive a message and get to know at that particular time your status as opposed to inconveniencing someone by asking them to go back to the hospital. You might not be infected with TB and then you incur costs of transport” [Male, 29 years]
Similarly, others noted that they hoped for follow-up interactions with LHWs to explain results more fully and allay concerns. These sentiments were emphasized by a young woman who was still hoping to talk to the LHW:“I do not support it. I do not support sending results through a message. I would love to be called on phone or actually a health worker coming and talk to you at home because you might again doubt whether you are talking to the right health worker that took your sample.” [Female, 22 years]
This participant said that her first inclination was to call the LHW for clarification. However, her husband stopped her; he felt that LHWs are busy and should not be bothered with telephone calls. Nonetheless, they expected a follow-up visit from the LHW.“I didn’t feel bad because the results were showing that I didn’t have TB… but still I wanted to talk to the LHW. I decided to accept the results but still wait for the LHW to tell me more.” [Female, 22 years]
Actions of household contacts after receiving a test result
A woman who received a message explaining that she had tested negative for TB said that she decided to wait at home to avoid bothering the LHW with frequent phone calls. She described how the household had a strong relationship with LHW and her expectation that they would meet again in person, at which time she would have the opportunity to ask for more explanation.“I decided to wait for her to come and explain to me because truthfully speaking I thought I had TB since I was staying close to my husband for a long time….” [Female, 22 years]
Contributors to household contacts’ intention to respond to SMS-suggested actions
Perceptions of adverse consequences of not adhering to the LHW’s instructions
This man believed that he could access TB care and treatment for his child only if he acted on the instructions from the LHW.“It seemed that in case you do not respond to the message they might not be able to help you. I was tested and the results were sent to me and I was requested to reply to it. So, I had to do it because I knew it means a lot when it comes to receiving treatment.” [Male, 37 years]
This young man was confident that he would achieve access to further evaluation if he replied to the message as directed.“One day it was sent to me and I replied to it and she immediately called back and said that she was going to come…I had been told that in case I replied they would provide support immediately” [Male, 19 years]
Beliefs about the curability of TB
The father’s expectation that his child could be cured motivated him to contact the LHW. Another household contact who received a negative TB result message and replied “HELP” reported feeling unwell and wanting to confirm his status and access treatment.“We had already been told that TB heals and medication is free, that we only need to be committed in taking it; not to miss and take it at the right time. I knew that at least my child will be able to take the right medication as opposed to taking wrong treatment for a long time without feeling fine or getting better.” [Male, 37 years]
“Since I was still feeling unwell I sent HELP. I said to myself: I need to know so that in case I need to get treatment I start right away when it is still early enough and get cured… The LHW called me and promised to come, which she did and decided to refer me to the clinic.” [Male, 19 years]
Anticipated support from lay health workers
One participant explained that he had developed trust in the LHW’s promise to see them through the clinic procedures following the home visit and other face-to-face interactions:“…the LHW had told me that she would help me in case I got there. It won’t require me to make line or anything; it would be just like an appointment.” [Male, 19 years]
Participants reported that their intentions to return to the clinic or request help in the future were premised on their belief that the LHW would support them if they did so.“Since I had received some counselling during the LHW visit…I found it easy to follow what I was told. I had earlier talked to the LHW again face to face.” [Male, 37 years]
Perceived barriers to responding to an SMS request for further evaluation
Several other household contacts also imagined that the distance to the clinic and busy working schedules would interfere with their intention to complete TB evaluation.“If I had been requested to go for further evaluation I would have failed since I was away upcountry and the results had been sent from Naguru clinic, which could inconvenience my working time. It would inconvenience my other duties…” [Male, 29 years]