Tuberculosis control in South Africa is hampered by high rates of initial loss to follow-up (failure to link to care and treatment after TB diagnosis).It is estimated that up to 25% of persons with positive sputum tests for TB are not started on TB treatment. Factors that contribute to this problem include 1) hand delivery of paper-copies of sputum results (delivered to clinics by laboratory messenger service) - leading to delayed laboratory turn-around-time, and 2) a paper-based system of recording and reporting of TB data to district and provincial authorities, leading to delays in reporting, and limitation of manageria response. TB epidemic modelling suggests that addressing the high initial loss to follow-up rate will contribute significantly to controlling TB incidence and prevalence over the next 10-15 years. mHealth has not been extensively applied either globally or in LMIC to programmes that return results of laboratory testing to health care providers and patients, despite significant potential benefits. Hypothesis and study design: We hypothesize that a mHealth intervention that relays sputum results from laboratory to health care workers (by an application on mobile handset with clinical decision support) and to patients (by personalised text message, with decision support) is a feasible and acceptable tool to facilitate patient and data management. When applied at scale, this intervention is likely to facilitate TB case finding and linkage to care and treatment. We describe a feasibility and acceptability assessment of this intervention through a pilot study, with evaluation through qualitative and quantitative methodology Methods: Using a standard software development lifecycle approach, in partnership with international role players in mHealth (Johns Hopkins), the South African National Health Laboratory service (NHLS), a South African mobile software provider, the Wits School of Public Health, we will design and pilot the intervention in a maximum of three primary health clinics in South Africa. In collaboration with patients, we will develop text messaging strategies by which patients will be informed of their sputum results. Through collection of process measures, we will assess its preliminary effect on data collection. Through in-depth interviews and focus group discussions we will explore acceptability amongst health care workers and patients. Finally, combining all data, and using a framework developed by the RSA Medical Research Council we will explore the potential of the intervention to go to scale. Findings from this pilot will contribute to development of a linkage to care system for MDR-TB, in development through the Global Fund 2013 award to the South African National Department of Health.

Public Health Relevance

This intervention (direct relaying of results of sputum TB testing to HCW and patients, together with tailored messaging and clinical decision support) will improve communication of laboratory results between HCW and patients, reduce time to treatment start, and reduce initial loss to follow-up. Built in reporting to TB programme managers will improve accountability of TB clinical staff, and improve programme management. Mathematical modelling of the TB epidemic in South Africa has shown that reduction in initial loss to follow-up will prevent ongoing TB transmission, and will significantly reduce incidence and prevalence of TB over the next 10-15 years.

National Institute of Health (NIH)
Fogarty International Center (FIC)
Exploratory/Developmental Grants (R21)
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Special Emphasis Panel (ZRG1-IMST-K (50))
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Povlich, Laura
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Aurum Institute Npc
South Africa
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Maraba, Noriah; Hoffmann, Christopher J; Chihota, Violet N et al. (2018) Using mHealth to improve tuberculosis case identification and treatment initiation in South Africa: Results from a pilot study. PLoS One 13:e0199687