title: Qualitative evaluation of a text messaging intervention to support patients with active tuberculosis: implementation considerations.
abstract: BACKGROUND
  Tuberculosis (TB) remains a major global public health problem and mobile health (mHealth) interventions have been identified as a modality to improve TB outcomes. TextTB, an interactive text-based intervention to promote adherence with TB medication, was pilot-tested in Argentina with results supporting the implementation of trials at a larger scale.
  
  
  OBJECTIVE
  The objective of this research was to understand issues encountered during pilot-testing in order to inform future implementation in a larger-scale trial.
  
  
  METHODS
  A descriptive, observational qualitative design guided by a sociotechnical framework was used. The setting was a clinic within a public pulmonary-specialized hospital in Argentina. Data were collected through workflow observation over 115 days, text messages (n=2286), review of the study log, and stakeholder input. Emerging issues were categorized as organizational, human, technical, or sociotechnical considerations.
  
  
  RESULTS
  Issues related to the intervention included workflow issues (eg, human, training, security), technical challenges (eg, data errors, platform shortcomings), and message delivery issues (eg, unintentional sending of multiple messages, auto-confirmation problems). System/contextual issues included variable mobile network coverage, electrical and Internet outages, and medication shortages.
  
  
  CONCLUSIONS
  Intervention challenges were largely manageable during pilot-testing, but need to be addressed systematically before proceeding with a larger-scale trial. Potential solutions are outlined. Findings may help others considering implementing an mHealth intervention to anticipate and mitigate certain challenges. Although some of the issues may be context dependent, other issues such as electrical/Internet outages and limited resources are not unique issues to our setting. Release of new software versions did not result in solutions for certain issues, as specific features used were removed. Therefore, other software options will need to be considered before expanding into a larger-scale endeavor. Improved automation of some features will be necessary, however, a goal will be to retain the intervention capability to be interactive, user friendly, and patient focused. Continued collaboration with stakeholders will be required to conduct further research and to understand how such an mHealth intervention can be effectively integrated into larger health systems.
authors: School of Nursing, Columbia University, New York, NY, United States. si2277@cumc.columbia.edu.
authors: Sarah J
authors: http://orcid.org/0000-0003-2980-0717
authors: SJ
authors: Iribarren
authors: Katherine A
authors: http://orcid.org/0000-0002-6568-4031
authors: KA
authors: Sward
authors: Susan L
authors: http://orcid.org/0000-0002-1820-0129
authors: SL
authors: Beck
authors: Patricia F
authors: http://orcid.org/0000-0002-2828-1778
authors: PF
authors: Pearce
authors: Diana
authors: http://orcid.org/0000-0001-6827-8103
authors: D
authors: Thurston
authors: Cristina
authors: http://orcid.org/0000-0002-5694-3396
authors: C
authors: Chirico
keywords: mHealth; sociotechnical evaluation; text messaging; tuberculosis