Pro Real Time Mobile
Nayra Wellinghoff
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Finding innovative methods to enhance Tuberculosis treatment adherence in Malaysia is imperative, given the rising trend of non-adhere TB patients. Direct Observed Therapy (DOTS) has been used to ensure Tuberculosis (TB) drug compliance worldwide. However, due to its inconvenience, digitalizing this system into a virtual monitoring system via a mobile app can help deliver a more efficient tuberculosis management system. A gamified video-observed therapy is developed that connects three users the patient, supervisor, and administrator, allowing drug monitoring and patient loss to follow up with the patient tracking system. Thus, the objective of this study is to determine the impact of Gamified Real-time Video Observed Therapy (GRVOTS) mobile apps on patient medication adherence rates and motivation.
71 patients from 18 facilities participated in the 8-week single-arm intervention study. GRVOTS mobile apps were installed in their mobile apps, and patients were expected to fulfill tasks such as providing Video Direct Observe Therapy (VDOTS) daily as well as side effect reporting. At 3-time intervals of baseline,1-month, and 2-month intervals, the number of VDOT taken, the Malaysian Medication Adherence Assessment Tool (MyMAAT), and the Intrinsic Motivation Inventory (IMI) questionnaire were collected. One-sample t-test was conducted comparing the VDOT video adherence to the standard rate of 80%. RM ANOVA was used to analyze any significant differences in MyMAAT and IMI scores across three-time intervals.
By utilizing GRVOTS, a mobile application based on gamification and real-time features, we can enhance motivation and medication adherence among TB patients, while also addressing the limitations of physical DOTS.
Tuberculosis has stood as the most concerning global infectious disease for three decades, with over 10 million new cases reported annually worldwide [1]. According to a model projection by Ismail N. et al. (2013), the observed and projected TB incidence cases in Malaysia from 1990 will reach up to 30,000 cases in 2030 [2]. After being diagnosed with Tuberculosis, patients are required to successfully finish a 6-month medication regimen utilizing Direct Observed Therapy Short Course (DOTS), a well-established method recognized globally for enhancing medication adherence in TB programs. Nevertheless, despite the introduction of physical DOTS in 1994, Malaysia has encountered persistent challenges with TB loss to follow-up prevelance fluctuating between 4.0% (2010) and 4.8% (2015), and more recently surging to 5.6%, as indicated by the most recent research data [3].
Mobile health technology offers significant potential to improve the management of chronic infectious diseases like tuberculosis (TB). It addresses the critical challenge of ensuring patient adherence to complete treatment courses, vital in preventing TB spread and drug-resistant strains. By fostering patient empowerment, self-management, and connecting patients with healthcare professionals, mobile health technology enhances disease management for TB and similar chronic infections [4,5,6].
Additionally, Abdul Rahim and Thomas (2017) emphasized the potential of gamification in improving treatment adherence, as evidenced in their study on using gamification to encourage medication adherence in epilepsy [10]. Their study demonstrated that a gamified approach to epilepsy treatment not only enhances patient adherence but also has the potential to positively influence public perceptions of the disease if shared with a broader audience. Game dynamics can improve user desire and motivation by establishing rules that encourage users to explore and learn about apps, thus maintaining usage sustainability [11]. With a balance of intrinsic and extrinsic rewards, gamification has the element of a design-thinking focused process to engage and motivate the audience into desired behaviors. Thus, it has the potential to transform dull routine tasks into a more enjoyable and motivating experience and has proven to increase intrinsic motivation [12].
A single-arm intervention study involves administering the intervention to a sample of individuals with a specific medical condition and tracking them over time to observe the resulting outcomes [14]. Between September and November 2022, a cross-sectional research approach was used to investigate how patients utilized GRVOTS over two months. Data collection was carried out with two established tools: the Malaysian Medication Adherence Assessment Tool (MyMAAT), which assesses medication adherence habits, and The Intrinsic Motivation Inventory (IMI), a questionnaire based on self-determination theory designed to measure intrinsic motivation levels. Data collection involved the use of a self-administered questionnaire, and the gathered information was recorded in an Excel format. One-sample t-test was conducted comparing the VDOT video adherence to the standard rate of 80%. RM ANOVA was used to analyze any significant differences in MyMAAT and IMI scores across three-time intervals. Data analysis was performed using Excel and exported to the Statistical Package for Social Science Software (SPSS version 28).
Participants who fit the recruitment criteria were offered mobile apps during their clinic visit. The informed consent form clearly explained that study participation was voluntary, and participants could withdraw from the study at any time without jeopardizing their health care. Their decision to withdraw had no impact on their relationship with their treatment center. If they wished to withdraw from study participation, they needed only to inform the principal investigator (PI), and no further data would be collected from that time onward.
Sample size estimation was calculated using the pairwise comparison formula. Preliminary data indicate that the control mean was 2.54 (SD:0.89) compared to intervention 3.41 (SD 0.89). If the type 1 error probability and precision are 0.05, we will need to study 55 samples. We managed to recruit 88 patients from 18 health facilities and analyzed 17 patients lost to follow-up.
Approximately 7% of video clips submitted during the first two months of treatment were corrupted because of a software bug that was subsequently fixed. Despite the corruption, the patient kept the video clip in their gallery and utilized WhatsApp as an alternative platform to share it with their supervisor. If the issue persists for more than three days, the patient will lose eligibility for GRVOTS, necessitating a shift to physical DOTS for ongoing treatment. However, similar occurrences are common in trial studies, as observed in various other research investigations [17]. Thus, in our main analysis, we assumed that the submission of a corrupted clip represented pill ingestion since patients were unaware that their submitted videos were corrupted. Table 2 shows descriptive statistics of the study variables.
As for the treatment adherence rate was calculated based on number of videos received over the total video expected. The t-test of the treatment adherence level indicates good treatment adherence of the participant of GRVOTS as a mobile application as shown in Table 3.
The results of this study can be categorized into four distinct outcomes: three outcomes pertain to the Intrinsic Motivation Questionnaire (IMI), specifically addressing Interest, Competence, and Choice, while the fourth outcome relates to the MyMAAT score. The comparison of mean percentage scores for the three components of IMI and MyMAAT across three different time intervals yielded three separate sets of results.
As for the implication from the trend, after post-hoc analysis, it is shown to be linear in trend which means constant small increase in MyMAAT score over time. It could be attributed to the habit of medication intake, which typically takes about 21 days or more to establish. Therefore, it might take more time to observe a significant difference in MyMAAT results compared to our 2-month intervention study [35].
This study found a significant improvement in patients with Tuberculosis disease motivation across subdomains of interest, competence, and choice after using the GRVOTS mobile apps throughout the 3-time interval. The time-intervention effect produces a significant difference in the mean percentage of IMI score of time between pre- and 1 to 2 months post-usage of GRVOTS, indicating that GRVOTS can increase patient motivation, especially among working-age tuberculosis patients. The findings align with many studies supporting that mobile phone apps can improve user motivation.In a study conducted by Jeno, Grytnes et al. (2017), the relationship between achievement scores, perceived competence, and intrinsic motivation in mobile app learning (specifically ArtsApp) was examined and compared to traditional book learning. The findings revealed a significant association between ArtsApp mobile app usage and achievement, with intrinsic motivation mediating this relationship [36].
As for the implication from the trend, out of the three motivation components measured, the subdomains of interest and choice showed significant quadratic trend increases across the three-time intervals. The increment indicates that the intervention had a gradual and increasingly beneficial effect on IMI scores, with the most significant changes occurring at T1 to T2 after the first month of mobile app usage. In other words, the gamification component in mobile apps was much appreciated and effective after a specific duration of usage, which was one month.
Out of all three subdomains, only competence showed a linear but not quadratic trend, which means that throughout the intervention, the motivation level of competence gradually and constantly increased. The competence component of mobile app gamification can constantly and gradually increase after intervention via several components of competency which are skills and gamification elements implemented.
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