Enhancing tuberculosis treatment support: A thematic analysis of interactive messages in a digital adherence technology trial to identify needs, challenges, and strategies for improvement

Designs must account for technological reliability, digital literacy, empathetic and adaptable human support, educational content, access challenges, and flexible, user-friendly features to address diverse patient needs and systemic barriers.

The primary objective was to assess user engagement with the Companion app within the Tuberculosis Treatment Support Tools (TB-TST) intervention and explore the types of interactive messages that promote treatment adherence and address patients’ needs.

The study used the TB-TST intervention, which includes the Companion application—a progressive web app allowing for daily medication/adherence reporting, messaging with treatment supporters (TSs), viewing treatment progress, symptom tracking, technical support, and an anonymous discussion forum. It also includes a urine drug metabolite test to objectively confirm adherence.

Five main themes were identified: living with TB (including the impact of COVID-19), medical and symptom guidance, healthcare coordination, treatment/intervention adherence, and technical issues.

Patients most frequently sent messages about managing symptoms and side effects, integrating TB treatment into daily life, coping with emotional distress, the impact of COVID-19, and technical or access issues with the application.

Personalized and empathetic TS communication led to better patient acceptance and engagement, while impersonal or delayed responses and generic reminders were associated with reduced interaction and sometimes disengagement from the application.

The COVID-19 pandemic created significant concern and disruption, with patients seeking advice about vaccine safety during TB treatment, treatment continuity, safety of daily activities, and COVID-TB interactions. This increased need for support and exacerbated challenges with care access.

Patients sought guidance on whether symptoms were normal, how to manage side effects (especially gastrointestinal issues), when to seek urgent care, and often needed reassurance to avoid unnecessary anxiety or hospital visits.

The intervention facilitated exchange with TSs who provided reassurance, practical strategies (like suggesting distraction activities), and referrals to psychological services. Emotional support was a significant part of the SM exchanges, helping to address anxiety, isolation, and stigma.

Patients frequently sought help with scheduling, confirming, or rescheduling appointments; navigating healthcare services; and obtaining medication refills. TSs provided administrative support to minimize disruptions in care.

Barriers included forgetfulness, being overwhelmed with other responsibilities, illness, technical issues (reporting glitches, session problems), limited internet connectivity or phone credit, and lack of required materials (e.g., test strips).

Issues included login failures, problems uploading photos, application glitches, lost data, and difficulties with navigation or device changes. TSs responded with step-by-step instructions, links, and troubleshooting support.

Recommendations included improving empathetic communication training for TSs, clarifying onboarding and guidance, enhancing emergency protocols, addressing application glitches, offering flexible reporting options, expanding mental health support and peer support, adding education to fight TB stigma, and exploring AI-powered 24/7 support.

Strengths included personalized communication, trust-building between TSs and patients, user-friendly adherence tracking, personalized reminders, timely information sharing, robust mental health support, streamlined healthcare coordination, effective technical support, and clear guidance on medication side effects.

Limiting factors were technical issues (connectivity, app glitches), lack of personalization or timely responses from TSs, digital literacy barriers, and contextual challenges such as lack of electricity, phone credit, or required materials.

The study included only drug-susceptible TB patients with smartphones in Argentina, limiting generalizability to those with drug-resistant TB, without smartphone access, or in different socioeconomic/geographic settings.

SM enabled real-time, bidirectional communication for symptom guidance, emotional support, care coordination, educational queries, and technical troubleshooting, making it a key tool for holistic, person-centered TB care.

Patients described feelings of despair, anxiety, isolation, fear about transmitting TB to loved ones, distress from family reactions, social stigma, and the emotional strain of prolonged illness and lockdown.

Suggestions included fixing app glitches, simplifying the interface, improving camera functionality, offering multiple reporting channels, enhancing technical support, and improving connectivity options for users with poor access.

It's recommended to incorporate testimonials from individuals who completed TB treatment to inspire others, continue using milestone recognition, and employ motivational, personalized reminders.

The high volume of messages about emotional distress underscores the need to integrate dedicated psychological support and referral pathways within TB care and digital interventions.

Designs must account for technological reliability, digital literacy, empathetic and adaptable human support, educational content, access challenges, and flexible, user-friendly features to address diverse patient needs and systemic barriers.

The primary objective was to assess user engagement with the Companion app within the Tuberculosis Treatment Support Tools (TB-TST) intervention and explore the types of interactive messages that promote treatment adherence and address patients’ needs.