Browsing by Author "Babirye, Diana"
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Item Anybody out there? A process evaluation of SMS sent to household TB contacts in Kampala, Uganda(ResearchGate, 2018) Amanda, J. Meyer; Babirye, Diana; Armstrong-Hough, Mari; Mark, David; Ayakaka, Irene; Katamba, Achilles; Haberer, Jessica E.; Davis, J. LucianPrevious studies have reported inconsistent effectiveness of SMS (short-messaging services) for improving health outcomes, but few have examined to what degree the quality, or “fidelity”, of implementation may explain study results. Objective: We sought to determine the fidelity of a one-time SMS intervention to promote uptake of TB evaluation services among household contacts of index TB patients. Methods: From February to June 2017, we nested a process evaluation of SMS delivery within the intervention arm of a randomized controlled trial of TB contact investigation in Kampala, Uganda. Because mobile service providers in Uganda do not provide delivery confirmations, we asked household TB contacts to confirm receipt of a one-time TB-related SMS by sending an SMS reply via a toll-free “short code.” Two weeks later, a research officer followed-up by telephone to confirm receipt of the one-time SMS and administer a survey. We considered participants lost-to-follow-up after three unsuccessful call attempts on three separate days over a one-week period. Results: Of 206 consecutive household contacts, 119 had an SMS initiated from the server. Thirty-nine (33%) were children aged 5-14, including 24 (20%) girls and 15 (13%) boys. Twenty-one (18%) were adolescents or young adults, including 14 (12%) young women and seven (6%) young men. Fifty-nine (50%) were adults, including 31 (26%) women and 28 (24%) men. Of 107 (90%) participants for whom we were able to ascertain SMS receipt status, 67% (n=72) confirmed SMS receipt, including 22% (n=24) by reply SMS and 45% (n=48) during the follow-up telephone survey. There were no significant clinical or demographic differences between those who did and did not report receiving the SMS message. 52% (n=56) reported ever reading the SMS. The cumulative likelihood of an SMS reaching its target and being read and retained by a participant was 19%. Conclusions: The fidelity of a one-time SMS intervention to increase uptake of household TB contact investigation and linkage to care was extremely low, a fact only discoverable through a detailed process evaluation. Our findings suggest the need for systematic process monitoring and reporting of implementation fidelity in both research studies and programmatic interventions employing mobile communications to improve health.Item A cost analysis of implementing mobile health facilitated tuberculosis contact investigation in a low-income setting(PLoS ONE, 2022) Turimumahoro, Patricia; Tucker, Austin; Gupta, Amanda J.; Tampi, Radhika P.; Babirye, Diana; Ochom, Emmanuel; Ggita, Joseph M.; Ayakaka, Irene; Sohn, Hojoon; Katamba, Achilles; Dowdy, David; Davis, J. LucianMobile health (mHealth) applications may improve timely access to health services and improve patient-provider communication, but the upfront costs of implementation may be prohibitive, especially in resource-limited settings. Methods We measured the costs of developing and implementing an mHealth-facilitated, homebased strategy for tuberculosis (TB) contact investigation in Kampala, Uganda, between February 2014 and July 2017. We compared routine implementation involving community health workers (CHWs) screening and referring household contacts to clinics for TB evaluation to home-based HIV testing and sputum collection and transport with test results delivered by automated short messaging services (SMS). We carried out key informant interviews with CHWs and asked them to complete time-and-motion surveys. We estimated program costs from the perspective of the Ugandan health system, using top-down and bottom- up (components-based) approaches. We estimated total costs per contact investigated and per TB-positive contact identified in 2018 US dollars, one and five years after program implementation. Results The total top-down cost was $472,327, including $358,504 (76%) for program development and $108,584 (24%) for program implementation. This corresponded to $320-$348 per household contact investigated and $8,873-$9,652 per contact diagnosed with active TB over a 5-year period. CHW time was spent primarily evaluating household contacts who returned to the clinic for evaluation (median 30 minutes per contact investigated, interquartile range [IQR]: 30–70), collecting sputum samples (median 29 minutes, IQR: 25–30) and offering HIV testing services (median 28 minutes, IQR: 17–43). Cost estimates were sensitive to infrastructural capacity needs, program reach, and the epidemiological yield of contact investigation. Conclusion Over 75% of all costs of the mHealth-facilitated TB contact investigation strategy were dedicated to establishing mHealth infrastructure and capacity. Implementing the mHealth strategy at scale and maintaining it over a longer time horizon could help decrease development costs as a proportion of total costs.Item Design and execution of a public randomization ceremony to enhance stakeholder engagement within a cluster randomized trial to improve tuberculosis diagnosis in Uganda(Contemporary clinical trials communications, 2021) Reza, Tania F.; Nalugwa, Talemwa; Nantale, Mariam; Adams, Katherine; Fielding, Katherine; Nakaweesa, Annet; Oyuku, Denis; Nabwire, Sarah; Musinguzi, Johnson; Ojok, Christopher; Babirye, Diana; Ackerman, Sara L.; Handley, Margaret A.; Kityamuwesi, Alex; Dowdy, David W.; Moore, David A.J.; Davis, J. Lucian; Turyahabwe, Stavia; Katamba, Achilles; Cattamanch, AdithyaPublic randomization ceremonies have been proposed as a strategy to strengthen stakeholder engagement and address concerns and misconceptions associated with trial randomization. However, there are few published examples that describe how to conduct a public randomization ceremony with meaningful stakeholder engagement or how such ceremonies impact stakeholder perceptions about randomization and the randomization process. Cluster randomization for the GeneXpert Performance Evaluation for Linkage to Tuberculosis Care (XPEL-TB) trial was conducted at a public randomization ceremony attended by 70 stakeholders in Kampala, Uganda. Presentations given by the Acting Assistant Commissioner from the Uganda National Tuberculosis and Leprosy Programme and trial investigators emphasized how the trial aimed to further national TB goals, as well as how stakeholders contributed to the intervention design. The purpose and process of randomization were described using simple text and visuals. Randomization was an interactive activity that required participation of stakeholders from each trial site. A survey administered to stakeholders at the end of the ceremony suggested high comprehension of randomization (98%), trust in the randomization process (96%), and satisfaction with randomization outcomes (96%). Public randomization ceremonies should be considered more routinely to engage stakeholders in and address potential concerns about the fairness and impartiality of the randomization process for community-based trials.Item Drop-out from the tuberculosis contact investigation cascade in a routine public health setting in urban Uganda: A prospective, multi-center study(PLoS ONE, 2017) Armstrong-Hough, Mari; Turimumahoro, Patricia; Meyer, Amanda J.; Ochom, Emmanuel; Babirye, Diana; Ayakaka, Irene; Mark, David; Ggita, Joseph; Cattamanchi, Adithya; Dowdy, David; Mugabe, Frank; Fair, Elizabeth; Haberer, Jessica E.; Katamba, Achilles; Davis, J. LucianSeven public tuberculosis (TB) units in Kampala, Uganda, where Uganda's national TB program recently introduced household contact investigation, as recommended by 2012 guidelines from WHO. Objective To apply a cascade analysis to implementation of household contact investigation in a programmatic setting. Design Prospective, multi-center observational study. Methods We constructed a cascade for household contact investigation to describe the proportions of: 1) index patient households recruited; 2) index patient households visited; 3) contacts screened for TB; and 4) contacts completing evaluation for, and diagnosed with, active TB. Results 338 (33%) of 1022 consecutive index TB patients were eligible for contact investigation. Lay health workers scheduled home visits for 207 (61%) index patients and completed 104 (50%). Among 287 eligible contacts, they screened 256 (89%) for symptoms or risk factors for TB. 131 (51%) had an indication for further TB evaluation. These included 59 (45%) with symptoms alone, 58 (44%) children <5, and 14 (11%) with HIV. Among 131 contacts found to be symptomatic or at risk, 26 (20%) contacts completed evaluation, including five (19%) diagnosed with and treated for active TB, for an overall yield of 1.7%. The cumulative conditional probability of completing the entire cascade was 5%. Conclusion Major opportunities exist for improving the effectiveness and yield of TB contact investigation by increasing the proportion of index households completing screening visits by lay health workers and the proportion of at-risk contacts completing TB evaluation.Item Feasibility of a short message service (SMS) intervention to deliver tuberculosis testing results in peri-urban and rural Uganda(Journal of clinical tuberculosis and other mycobacterial diseases, 2019) Babirye, Diana; Shete, Priya B.; Farr, Katherine; Nalugwa, Talemwa; Ojok, Christopher; Nantale, Mariam; Oyuku, Denis; Ayakaka, Irene; Katamba, Achilles; Davis, J. Lucian; Nadunga, Diana; Joloba, Moses; Moore, David; Cattamanchi, AdithyaPre-treatment loss to follow-up is common for patients diagnosed with tuberculosis (TB) in highburden countries. Delivering test results by Short-Messaging-Service (SMS) is increasingly being considered as a solution, but there is limited information about its feasibility as a public health tool in low resourced settings. Objective: We sought to assess the feasibility of utilizing SMS technology to deliver TB test results during routine TB diagnostic evaluation in Uganda. Methods: We conducted a single arm interventional pilot study at four community health centers in Uganda that referred sputum samples to a district hospital for GeneXpert-MTB/RIF (Xpert) testing (Cepheid, USA). Using existing GxAlert-software (SystemOne,USA), we set up an automated SMS platform to send Xpert results to patients and referring health centers. We assessed each step of the SMS delivery cascade for consecutive patients who presented to these four community health centers between December 2015 and March 2016 and underwent Xpert testing. Results: Of 233 patients enrolled, 161 (69%) had phone numbers recorded on individual Xpert referral forms. Phone numbers were entered into Xpert device software in the correct format for 152 (94%) patients. GxAlertsoftware generated an automated SMS reporting Xpert results for 151 (99%) patients and delivered it successfully to mobile phone service providers for 145/151 (96%). Of the 123 patients reached by phone to determine receipt of test results, 114 (93%) confirmed SMS receipt. SMS-based delivery of Xpert results was verified for 114/233 (49%) patients overall. In contrast, phone calls to health centers confirmed that health centers received messages for 222/233 (95%) patients. Conclusion: Reporting Xpert results via automated SMS is technically feasible and results in approximately half of patients receiving their test results immediately. Additional research should be done to address process inefficiencies in order to maximize impact of this technology and link its successful utilization to improved patient outcomes.Item Feasibility, acceptability, and adoption of fingerprint scanning during contact investigation for tuberculosis in Kampala, Uganda: A parallel-convergent, mixed-methods analysis(PeerJ Preprints, 2018) White, Elizabeth B.; Meyer, Amanda J.; Ggita, Joseph M.; Babirye, Diana; Mark, David; Ayakaka, Irene; Haberer, Jessica E.; Katamba, Achilles; Armstrong-Hough, Mari; Davis, J. LucianIn resource-constrained settings, challenges with unique patient identification may limit continuity of care, monitoring and evaluation, and data integrity. Biometrics offer an appealing but understudied potential solution. Methods We conducted a mixed-methods study to understand feasibility, acceptability, and adoption of digital fingerprinting for patient identification in a study of household TB contact investigation in Kampala, Uganda. We tested associations between demographic, clinical, and temporal characteristics and failure to capture a digital fingerprint. We used generalized estimating equations and a robust covariance estimator to account for clustering. We evaluated clustering of outcomes by household and community health worker by calculating intra-class correlation coefficients. To understand determinants of intended and actual use of fingerprinting technology, we conducted fifteen in-depth interviews with community health workers and applied a widely used conceptual framework, the Technology Acceptance Model 2. Results Digital fingerprints were captured in 74% of participants, with extensive clustering by household (ICC = 0.99) arising from hardware (XX%) and software (XX%) failures. Clinical and demographic characteristics were not significantly associated with fingerprint capture. Community health workers successfully fingerprinted all contacts in 70% of households, with modest clustering of outcomes by CHW (ICC = 0.18). Fingerprinting success at the household level declined over time (Spearman’s rho = 0.30, P < 0.001). In interviews, CHWs reported that fingerprinting non-capture events lowered their own perception of the quality of the technology, threatened their social image, and made the technology more difficult to use. Conclusions We found digital fingerprinting to be feasible and acceptable for indvidual identification, but problems implementing the hardware and software led to a high failure rate. Although CHWs found fingerprinting to be acceptable in principle, their intention to use the technology was tempered by perceptions that it was inconsistent and of questionable value. We emphasize the need for routine process evaluation of biometrics and other digital technologies during implementation in resource-constrained settings.Item Implementation, feasibility, and acceptability of 99DOTS-based supervision of treatment for drug- 2 susceptible TB in Uganda(medRxiv, 2022) Kiwanuka, Noah; Kityamuwesi, Alex; Crowder, Rebecca; Guzman, Kevin; Berger, Christopher A.; Lamunu, Maureen; Namale, Catherine; Kunihira Tinka, Lynn; Sanyu Nakate, Agnes; Ggita, Joseph; Turimumahoro, Patricia; Babirye, Diana; Oyuku, Denis; Patel, Devika; Sammann, Amanda; Stavia, Turyahabwe; Dowdy, David; Katamba, Achilles; Cattamanchi, Adithya99DOTS is a low-cost digital adherence technology that allows people with tuberculosis (TB) to self-report treatment adherence. There are limited data on its implementation, feasibility, and acceptability from sub-Saharan Africa. We conducted a longitudinal analysis and cross-sectional surveys nested within a stepped-wedge randomized trial at 18 health facilities in Uganda between December 2018 and January 2020. The longitudinal analysis assessed implementation of key components of a 99DOTS-based intervention, including self-reporting of TB medication adherence via toll-free phone calls, automated text message reminders and support actions by health workers monitoring adherence data. Cross-sectional surveys administered to a subset of people with TB and health workers assessed 99DOTS feasibility and acceptability. Composite scores for capability, opportunity, and motivation to use 99DOTS were estimated as mean Likert scale responses. Among 462 people with pulmonary TB enrolled on 99DOTS, median adherence was 58.4% (inter-quartile range [IQR] 38.7-75.6) as confirmed by self-reporting dosing via phone calls and 99.4% (IQR 96.4-100) when also including doses confirmed by health workers. Phone call-confirmed adherence declined over the treatment period and was lower among people with HIV (median 50.6% vs. 63.7%, p<0.001). People with TB received SMS dosing reminders on 90.5% of treatment days. Health worker support actions were documented for 261/409 (63.8%) people with TB who missed >3 consecutive doses. Surveys were completed by 83 people with TB and 22 health workers. Composite scores for capability, opportunity, and motivation were high; among people with TB, composite scores did not differ by gender or HIV status. Barriers to using 99DOTS included technical issues (phone access, charging, and network connection) and concerns regarding disclosure. 99DOTS was feasible to implement and highly acceptable to people with TB and their health workers. National TB Programs should offer 99DOTS as an option for TB treatment supervision.Item Study protocol and implementation details for a pragmatic, stepped-wedge cluster randomised trial of a digital adherence technology to facilitate tuberculosis treatment completion(BMJ Open, 2020) Crowder, Rebecca; Kityamuwesi, Alex; Kiwanuka, Noah; Lamunu, Maureen; Namale, Catherine; Kunihira Tinka, Lynn; Sanyu Nakate, Agnes; Ggita, Joseph; Turimumahoro, Patricia; Babirye, Diana; Oyuku, Denis; Allen Berger, Christopher; Tucker, Austin; Patel, Devika; Sammann, Amanda; Dowdy, David; Turyahabwe, Stavia,; Cattamanchi, Adithya; Katamba, AchillesLow-cost digital adherence technologies (DATs) such as 99DOTS have emerged as an alternative to directly observed therapy (DOT), the current standard for tuberculosis (TB) treatment supervision. However, there are limited data to support DAT scale-up. The ‘DOT to DAT’ trial aims to evaluate the effectiveness and implementation of a 99DOTS-based TB treatment supervision strategy. Methods and analysis This is a pragmatic, stepped-wedge cluster randomised trial, with hybrid type 2 effectiveness-implementation design. The trial will include all adults (estimated N=1890) treated for drug-susceptible pulmonary TB over an 8-month period at 18 TB treatment units in Uganda. Three sites per month will switch from routine care (DOT) to the intervention (99DOTS-based treatment supervision) beginning in month 2, with the order determined randomly. 99DOTS enables patients to be monitored while self-administering TB medicines. Patients receive daily automated short message service (SMS) dosing reminders and confirm dosing by calling toll-free numbers. The primary effectiveness outcome is the proportion of patients completing TB treatment. With 18 clusters randomised into six steps and an average cluster size of 15 patients per month, the study will have 89% power to detect a 10% or greater increase in treatment completion between the routine care and intervention periods. Secondary outcomes include more proximal effectiveness measures as well as quantitative and qualitative assessments of the reach, adoption and implementation of the intervention. Ethics and dissemination Ethics approval was granted by institutional review boards at Makerere University School of Public Health and the University of California San Francisco. Findings will be disseminated through peer-reviewed publications, presentations at scientific conferences and presentations to key stakeholders.