Is it possible to encourage TB testing and detect missing TB cases via community-level promotion of a self-screening mobile application? Quasi-experimental evidence from South Africa.

Abstract

While mobile health (mHealth) interventions are widespread, few studies assess impacts at the population level in low-income and middle-income countries. South Africa's tuberculosis (TB) burden is high, and a substantial share of cases remain undiagnosed. We evaluate the impacts of community activations of TBCheck-a WhatsApp/USSD-based chatbot that allows individuals to evaluate themselves for TB risk. We use a quasi-experimental approach comparing treated and control subdistricts nationally before and after community activations using dashboard data from the TBCheck platform and weekly or quarterly subdistrict TB test data from the National Health Laboratory Service. Dependent variables are the number of self-screening tests on the platform, total tests and number of positive tests per subdistrict. We employ dynamic difference-in-difference models accounting for subdistrict unobservables and time trends using weekly data, and synthetic control methods matching on preintervention trends in outcomes using quarterly data. Impact estimates suggest an increase in the number of self-screening tests on the platform (487.53, p-value<0.01) as well as TB tests (107.90, p-value=0.05) in treated relative to control subdistricts due to intervention activities in the week of the intervention. After 2 weeks, impacts on the number of self-screening tests are insignificant (-6.18, p=0.23), and after 1 week, impacts on TB tests are insignificant (36.44, p-value=0.32). Activation activities associated with TBCheck led to short-lived and variable impacts on uptake and tests in target subdistricts. Alternative strategies are required for sustained uptake of such mHealth tools.