mHealth for Tuberculosis Treatment Adherence: A Framework to Guide Ethical Planning, Implementation, and Evaluation

Adherence to tuberculosis (TB) treatment is important for promoting individual and public health. Poor adherence results in more individual suffering and death as well as more costly treatment as treatment regimens lengthen and drug resistance develops. As resource allocation pressures intensify under the Sustainable Development Goals and the global push for universal health coverage, exploring novel ways of improving adherence is timely and important. Mobile health (mHealth) holds considerable promise to improve quality and efficiency in health care. Yet its potential for TB adherence remains largely unexplored, and there is a lack of people-centered mHealth approaches responsive to the complexity of real life. Also lacking are ethical evaluations of mHealth interventions, particularly those considering the nuances of diseaseand goal-specific interventions. Perceived and real acceptability cannot be taken for granted. The planning, implementation, and evaluation of mHealth interventions for TB treatment adherence must be guided by values as much as by technical innovation. In this article, we describe salient mHealth approaches to monitor and enhance TB treatment adherence, establish a framework for consideration of the central ethical issues, particularly when mHealth is paired with incentives, and outline a model to help guide the ethical planning, implementation, and evaluation of future mHealth interventions for adherence. In doing so, we highlight areas of ethical concern as well as opportunities for ethical improvement over direct observation of therapy (DOT), the global standard for monitoring TB treatment adherence.