Title: Stakeholders’ Attitudes, Perceived Barriers, and Benefits of Using Video Observed Treatment for Monitoring Tuberculosis Patients in Uganda: A Qualitative Study (Preprint)

BACKGROUND Directly Observed Therapy (DOT) is the recommended standard for monitoring adherence to tuberculosis (TB) treatment worldwide, but it is challenging to implement in resource-limited settings. DOT is labor-intensive and often burdensome for both patients and healthcare workers. Video directly observed therapy (VDOT) is a novel patient-centered alternative that uses mobile technology to ‘observe’ patients taking medication remotely. However, the attitudes, perceptions, and acceptability of end-users have not been evaluated in Africa. OBJECTIVE The study aimed to evaluate the stakeholders’ attitudes and perceived barriers and benefits of using VDOT for monitoring TB patients in urban Uganda. METHODS A qualitative cross-sectional study was conducted in Kampala, Uganda, from April to May 2018. We conducted five focus group discussions, each composed of six participants. Stakeholder groups included male and female TB patients (n=2 groups), health providers (n=1), caregivers (n=1), and community DOT volunteer workers (n=1). Guided by the Technology Acceptance Model (TAM), we explored several dimensions including perceived usefulness, perceived ease of use, intent to use, and the external variables that affect the adoption of VDOT. Eligible participants were 18 years or older who provided written informed consent. We included only TB patients who had been on treatment for at least two months to ensure that they were no longer infectious. A convenience sample of patients was recruited at one of the TB clinics in Kampala to constitute two focus groups stratified by sex. Health provider and community volunteer groups were composed of available health workers. Trained interviewers conducted unstructured interviews, which were audio-recorded, transcribed, and analyzed into emerging themes using content analysis. RESULTS VDOT was acceptable across all categories of stakeholders interviewed. Health providers and community DOT workers perceived the potential usefulness and ease of use. In contrast, patients perceived the benefits of saving time and money because of the minimal need to travel to clinics for in-person monitVDOT was acceptable across all categories of stakeholders interviewed. Health providers and community DOT workers perceived the potential usefulness and ease of use. In contrast, patients perceived the benefits of saving time and money because of the minimal need to travel to clinics for in-person monitoring. Emergent themes included privacy concerns about unintended disclosure of TB disease status and the lack of skills required to use the VDOT technology. The respondents identified external variables, such as limited access to the internet and electricity. The majority of participants perceived the costs of acquiring a smartphone and paying for internet access as significant barriers to the use of VDOT. Female patients expressed concerns about how recording videos using the VDOT app might interfere with their domestic work time, thereby becoming an inconvenience.oring. Emergent themes included privacy concerns about unintended disclosure of TB disease status and the lack of skills required to use the VDOT technology. The respondents identified external variables, such as limited access to the internet and electricity. The majority of participants perceived the costs of acquiring a smartphone and paying for internet access as significant barriers to the use of VDOT. Female patients expressed concerns about how recording videos using the VDOT app might interfere with their domestic work time, thereby becoming an inconvenience CONCLUSIONS VDOT was universally perceived as acceptable and beneficial to the main TB stakeholders in the urban study setting. However, we identified perceived privacy concerns, limited technology skills, and costs related to using VDOT. We recommend careful consideration of the potential barriers when adopting mHealth tools for monitoring treatment adherence in this local African context.