PONE-D-24-05025Acceptability of Digital Adherence Technologies to support people with drug-susceptible TB in South AfricaPLOS ONE

Dear Dr. Dube,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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ACADEMIC EDITOR:  This manuscript provides a timely and important perspective on the importance of differentiated TB care  and the potential use of DATs to support adherence in a South African context. The analysis is detailed and practical in nature. The authors are to be congratulated. There are a few minor revisions or points of clarification, which will further strengthen your submission. However, overall, this is a strong piece of research. In addition to reviewer suggestions, which you will find below, please make the following recommended revisions: 

• In the abstract, write 'and/or' instead of 'and or' (line 28)
• Proofread spacing around references (see line 110 for example) and also remove full-stops for titles and sub-headings
• Elaborate more on what was done to manage the pre-existing relationships between data collectors and interviewees mentioned in lines134-5.  Did data collectors reflect on this in field notes? Was this discussed during the consent process. Consider revisiting this in the limitations section as well.
• The idea of sampling to reach data saturation was mentioned in line 140. However, this was not addressed in terms of how the final sample was decided. Clarify if data analysis was happening concurrently with data collection so that sampling ended once saturation was met or if other factors influenced the final sample. The term saturation in the analysis section (line 166) seemed to imply a different concept of saturation, involving the three coders rather than something that informed sampling. 
• Clarify the language(s) of interviews and who was involved in the translation and transcription process (a service or authors) in lines 152-53
• Specify a reference for the qualitative analysis (if grounded in a particular form of thematic analysis) on line 165
• Move up the UTAUT reference to line 168.

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Sara Jewett Nieuwoudt, Ph.D, MPH

Academic Editor

PLOS ONE

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

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Reviewer #1: Overall, this is a well written article which demonstrates the potential for these technologies to assist with TB medication adherence in South Africa. Minor comments are below:

Abstract

-Recommendation to add a sentence or two about the number of people with TB globally and/or in South Africa.

Intro

-You need a sentence or two to say something about TB in South Africa (see below for line 110).

-line 60: spell out health care workers

-Briefly say what DOT is

Methods

-line 110” “In 2022 the TB incidence in South Africa was 280K.” This belongs in the introduction.

-line 111: the districts were Tshwane and Bojanala? I would just say that.

-line 111: “conducted at public health clinics providing care”. I would change to something like “conducted at public health clinics where care for TB was offered…” The former sounds like the clinics themselves were providing care.

-Data collection: what is the definition of “good adherence” vs “poorer adherence”. This needs to be stated somewhere in methods.

-Data collection: line 114 you say intended to conduct 20 interviews which makes one think that you did not do this many interviews? If you did do this number of interviews, be direct and just say we conducted x interviews. If not, you can say you intended to do so many, but only ended up doing x because of whatever reason. It’s also confusing that in the findings section the numbers are different as you say 37 PWTB and 35 HCW were approached. Clarification would be helpful.

Findings

-Line 180: 37 PWTB, 35 HCW + stakeholders were approached. Be consistent. If you are going to split out HCW and stakeholders in other sections of the paper please do that throughout. Table 1 also lumps HCW & stakeholders together. You need to decide if you want to treat these groups as separate or lump them together.

-Line 180: The issue above also makes it difficult to follow the math for the number of participants. 2 people declined from each group so 37-2=35 and 35-2=33 but then somehow we end up with 26 HCWs which does not add up.

Reviewer #2: It is good to dig into approaches increase patients adherence to long treatments for killer diseases like Tuberculosis. However these technologies were or how much successful they were, it is paramount to share experiences so other researchers can develop more or find alternative approaches.

Reviewer #3: This is a qualitative study from South Africa in which the authors evaluated the acceptability of digital adherence technologies or DATs to support people receiving treatment for drug-susceptible tuberculosis (PWTB). There have been few studies examining the acceptability and feasibility of DATs among PWTB, HCWs and stakeholders in low and middle-income countries. Therefore, the authors set out to investigate the key factors associated with the use of smart pill boxes and labels alongside differentiated care in adults receiving treatment for drug-sensitive TB, in healthcare workers, and stakeholders in South Africa.

The study was nested within the Adherence Support Coalition to End TB (ASCENT) trial, a multi-country cluster randomized trial in which two DATs (a smart pillbox and a cellphone-based strategy) combined with differentiated care were used to support PWTB. The present study’s focus is on South Africa. In-depth interviews were conducted with purposively selected PWTB, healthcare workers, and stakeholders. Data were analyzed by the inductive thematic analysis and Unified Theory of Acceptance and Use of Technology was the framework used to synthesize and summarize the findings.

The authors main findings were that facilitating factors for the pillbox were alarm reminder, storage, ease of use, not requiring a phone, social support, and portability, whereas the barriers were its lack of portability for some of the PWTB and the fact that it malfunctioned. As to the use of labels with SMS, facilitating factors were ease of use among the young, daily confirmation messages, social support, privacy, and portability. Barriers to the use of labels were older age, illiteracy, forgetting to send the SMS, lacking understanding, no cell phone access, power cuts, and unresolvable technical glitches. The authors highlight that the use of DATs and differentiated care may be stigmatizing and that further work may be needed to make them less stigmatizing.

The manuscript is well written and provides a wealth of information on the methodology used for data analysis. The results are clearly presented and easy to interpret. Reasons for non-participation are described, and the participants profile are presented. Direct quotes are provided throughout the results that illustrate the themes well and support the authors’ interpretation.

I highly recommend this manuscript for publication as it is technically sound and provides a valuable understanding of factors that influence acceptability of DATs in PWTB in low- and middle-income settings.

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Reviewer #1: No

Reviewer #2: Yes:  LAYTH AL-SALIHI

Reviewer #3: No

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

PONE-D-24-05025R1

Dear Dr. Dube,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Sara Jewett Nieuwoudt, Ph.D, MPH

Academic Editor

PLOS ONE