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Cited by 18Tuberculosis Research and EpidemiologyMobile Health and mHealth ApplicationsMedication Adherence and Compliance

The DOI matches its Crossref record; 17 of the 19 references it cites were found in a registry or an index.

Implementation, feasibility, and acceptability of 99DOTS-based supervision of treatment for drug-susceptible TB in Uganda

Open access
Kiwanuka, Noah, Kityamuwesi, Alex, Crowder, Rebecca, Guzman, Kevin, Berger, Christopher A., Lamunu, Maureen, Namale, Catherine, Kunihira Tinka, Lynn, Nakate, Agnes Sanyu, Ggita, Joseph, Turimumahoro, Patricia, Babirye, Diana, Oyuku, Denis, Patel, Devika, Sammann, Amanda, Turyahabwe, Stavia, Dowdy, David W., Katamba, Achilles, Cattamanchi, Adithya·2023·PLOS Digital Health
DOI 10.1371/journal.pdig.0000138PMC PMC10313004

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Abstract

99DOTS 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.

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Crossref · 10.1371/journal.pdig.0000138

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  • Phased introduction of the 99DOTS intervention in Kiwanuka et al. 2023 ensured that all clusters eventually received the intervention while enabling a rigorous evaluation of its impact on TB treatment adherence.

    “Phased introduction of the 99DOTS intervention, ensuring that all clusters eventually received the intervention while enabling a rigorous evaluation of its impact on TB treatment adherence.”

    From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [85]

    The Study setting and design section describes a stepped-wedge randomized trial at 18 health facilities, with a 99DOTS intervention period at each facility. It does not explicitly say that every cluster received the intervention. The same section says the parent trial assessed effectiveness against routine care, while the Introduction identifies treatment completion as its reported outcome; this paper assessed adherence during 99DOTS use, not the intervention’s impact on adherence. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • Health facilities in Kiwanuka et al. 2023 were randomly assigned to receive the intervention at different times using a stepped-wedge cluster randomized trial design.

    “Health facilities were randomly assigned to receive the intervention at different times using a stepped-wedge cluster randomized trial design.”

    From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [85]

  • The sequence of implementation in Kiwanuka et al. 2023 was randomly determined.

    “The sequence of implementation was randomly determined.”

    From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [85]

  • The sample size calculation in Kiwanuka et al. 2023 assumed that 20% of enrolled patients would have TB, and the time from enrollment to TB treatment initiation would be a median of 10 days. The study aimed to have 95% confidence and more than 90% power to detect a minimum of 2 days reduction in time to TB treatment.

    “The sample size calculation assumed that 20% of enrolled patients would have TB, and the time from enrollment to TB treatment initiation would be a median of 10 days. The study aimed to have 95% confidence and more than 90% power to detect a minimum of 2 days reduction in time to TB treatment.”

    From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [85]

    Split into 2 atoms — 0 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 2 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

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Citations

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2 of the 19 references couldn’t be matched to a known paper.

Research works printed but not linked: 2

  1. E Efo, 2021, Acceptability, Feasibility and Accuracy of 99DOTS Adherence Technology in Mining Region of Tanzania., 2021 IST-Africa Conference (IST-Africa)
  2. StataCorp, 2017, Stata Statistical Software: Release 15

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Metadata

Authors
Kiwanuka, N., Kityamuwesi, A., Crowder, R., Guzman, K., Berger, C. A., Lamunu, M., Namale, C., Kunihira Tinka, L., Nakate, A. S., Ggita, J., Turimumahoro, P., Babirye, D., Oyuku, D., Patel, D., Sammann, A., Turyahabwe, S., Dowdy, D. W., Katamba, A., & Cattamanchi, A.
Affiliations
  • Makerere University (UG)
  • San Francisco General Hospital (US)
  • University of California, San Francisco (US)
  • Ministry of Health (UG)
  • Johns Hopkins University (US)
Corresponding author
Cattamanchi, Adithya
ORCID
Venue
PLOS Digital Health
Publisher
Public Library of Science (PLoS)
Published
2023-06-30
Volume
2
Issue
6
Pages
e0000138
ISSN
2767-3170 (ISSN-L)
DOI
10.1371/journal.pdig.0000138
PMC
PMC10313004
OpenAlex
W4382752395
Cited by
17
References
19
Citations by year
2026: 5 · 2025: 5 · 2024: 4 · 2023: 3
FWCI
3.52
Type
journal article
Language
en
Open access
Licence
Locations
  • PLOS Digital Health (publishedVersion, cc-by)
  • medRxiv (acceptedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • eScholarship (California Digital Library) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
Stop TB Partnership (STBP/TBREACH/GSA/W6-37)
Topics
  • Health Sciences › Medicine › Infectious Diseases › Tuberculosis Research and Epidemiology
  • Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
  • Health Sciences › Medicine › Family Practice › Medication Adherence and Compliance
Keywords
drug-susceptible tuberculosis, medication adherence, SMS reminders, health worker support, HIV coinfection, implementation feasibility, acceptability, technology adoption barriers, Uganda

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