Acceptability of Digital Adherence Technologies to support people with drug-susceptible TB in South Africa

Background Tuberculosis (TB) remains a challenge in South Africa, with an estimated 280,000 new cases reported in 2022. Digital Adherence Technologies (DATs) may be important tools to improve adherence to TB treatment. However, there is limited knowledge about facilitators and barriers to implementing these technologies in South Africa. Methods This qualitative study was embedded within the Adherence Support Coalition to End TB cluster-randomised trial which implemented the two technologies: a smart pillbox and/or a cell phone-based strategy similar to 99DOTS (labels), plus differentiated care, to support people with drug-sensitive TB (PWTB). In-depth interviews were conducted with purposively sampled participants comprising PWTB, Healthcare Workers (HCWs) and stakeholders. Inductive thematic analysis was used for data analysis, while the Unified Theory of Acceptance and Use of Technology (UTAUT) framework served as the overarching framework to synthesize and summarise the findings. Findings Sixty-eight interviews were conducted: 35 with PWTB and 33 with HCWs and stakeholders. Facilitating factors for the pillbox were alarm reminder, storage, ease of use, not requiring a phone, social support, and portability. Barriers to the pillbox were that some found the box unportable and others experienced box malfunctioning. Facilitating factors for the labels were ease of use among the young, daily confirmation messages, social support, privacy, and portability. Barriers to implementing these DATs were older age, illiteracy, forgetting to send the SMS, lacking understanding, no cell phone access, power cuts, and unresolvable technical glitches. While differentiated care improved the client-provider relationship, some PWTB felt home visits were stigmatising. HCWs and stakeholders expressed willingness to scale up DATs because they improved their working conditions, and it was advantageous for the PWTB. Conclusions Smart pillbox and labels had features which favoured their acceptability and there were also DAT specific barriers. DATs may improve person-centredness in TB care. Future guidelines should consider acceptability, differing situations, and allowing flexibility to possibly increase uptake and utilisation of DATs.