|
Joaquim
Teixeira Netto https://orci=
d.org/0000-0002-7392-9166 |
Doutor, Fund= ação Oswaldo Cruz (Fiocruz)- Brasil e Universidade NOVA de Lisboa (UNL), Portu= gal. joaquimtnetto@gmail.com, |
|
Melanie
Raimundo Maia https://orcid.org/0000-0003-3695-0537=
|
Doutora, Universidade NOVA de Lisboa (UNL), Portugal. melaniemaia@gmail.com= |
|
Cláudia
Alexandra da Cunha Pernencar https://orcid.org/0000-0001-8981-2133<= /span> |
Doutora, Universidade NOVA de Lisboa (UNL), Portugal.claudiapernencar@fcsh.unl.pt |
|
Ana
Margarida Barreto |
Doutora, Fac=
uldade
de Ciências Sociais e Humanas da Universidade Nova de Lisboa (UNL, ambar=
reto@fcsh.unl.pt |
RESUMO
O uso da Tecnologia da Informação e Comunicação (TIC) é uma ferramen=
ta
poderosa em todas as áreas do conhecimento, inclusive na saúde. No setor sa=
úde,
há contribuições significativas do uso de novas tecnologias, e a Organização
Mundial da Saúde considera o uso de tecnologias digitais uma ação important=
e na
redução da incidência de tuberculose em populações vulneráveis. Este artigo=
tem
como objetivo descrever o processo de desenvolvimento de aplicativo para
controle e monitoramento da tuberculose por meio do gerenciamento do seu
processo terapêutico. A abordagem metodológica inclui a Metodologia de Pesq=
uisa
Design Science, abrangendo revisão de literatura, desenvolvimento
inicial de protótipo no Brasil e experiência do usuário em Portugal utiliza=
ndo
validação de Inteligência Artificial (IA) com Eye Tracking. Os
resultados orientam a equipe de pesquisa a melhorar os recursos de
monitoramento e acompanhamento de pacientes do aplicativo de tuberculose.
Simulações utilizando IA para validação da aplicação demonstraram a
possibilidade de simular sua utilização, possibilitando antecipar problemas=
e
melhorar a aplicação.
Palavras-chave: Tuberculose; saúde
pública; saúde digital; tecnologia digital; inteligência artificial.
ABSTRACT
The use of Information and Communication Techno=
logy
(ICT) is a powerful tool in all fields of knowledge, including health. In t=
he
health sector, there are significant contributions from using new technolog=
ies,
and the World Health Organization considers the use of digital technologies=
an
important action in reducing tuberculosis incidence in vulnerable populatio=
ns.
This article aims to describe the process of app development for controlling
and monitoring tuberculosis through the management of its therapeutic proce=
ss.
The methodological approach includes Design Science Research Methodology,
encompassing literature review, initial prototype development in Brazil, and
user experience in Portugal using Artificial intelligence (IA) validation w=
ith
Eye Tracking. Results guide the research team to improve the patient monito=
ring
and follow-up features of the tuberculosis app. Simulations using AI to
validate the application demonstrated the possibility of simulating its use,
making it possible to anticipate problems and improve the application.
Keywords: Tuberculosis;<=
/span> public health;<=
/span> digital health; digital technology; artificial
intelligence.
Recebido
em 12/08/2024. Aprovado em 15/07/2=
025.
Avaliado pelo sistema double blind
https://doi.org/10.22279/navus.v16.1986
1 INTRODUC=
TION
=
According
to the United Nations (UN), tuberculosis (TB) is one of the leading causes =
of
death worldwide. Until the occurrence of the Coronavirus (COVID-19) pandemi=
c,
TB was the leading cause of death from a single infectious agent (WHO, 2022=
).
The World Health Organization (WHO), through successful experiences around =
the
world in the use of digital technologies to combat TB, developed a document=
for
the implementation of digital TB solutions (Who, 2017).
=
The
strategic plan from 2021 to 2025 to end TB as a public health issue, launch=
ed
in 2021 by the Brazilian Ministry of Health, establishes that the cure rate
should be greater than 90% and the treatment abandonment rate should be less
than 5%. This strategic plan emphasizes the urgency of adopting new strateg=
ies
according to the Brazilian Ministry of Health (2021), such as: 1) Prevention
and comprehensive patient-centered care; 2) Integrated policies and support
systems; and 3) Intensification of research and innovation.
=
Information
and Communication Technologies (ICTs) have been used as an important and
innovative approach to assist in health. During the COVID-19 pandemic, the =
use
of health mobile applications intensified worldwide to avoid COVID-19
contamination and improve response times to different requests (Netto, Hartz
& Magalhães, 2022). Likewise, TB applications were used to for different
purposes. A survey conducted by Keutzer et al. (2020) identified 55 mobile
phone applications developed specifically for TB, with the following
distribution: n=3D29 (53%) designed for disease guidance; n=3D8 (15%) desig=
ned to
monitor patient adherence; n=3D6 (11%) for dosage treatment adjustment; n=
=3D3 (6%)
focused on tuberculosis diagnosis; and n=3D9 (16%) related to other subject=
s.
=
Design
Science Research Methodology (DSRM), through its six-step iterative sequenc=
e,
allows the application prototype to be well-adapted, avoiding unnecessary
rework by the development team (Peffers et al., 2007). To evaluate t=
he
application's design, artificial intelligence was used through eye-tracking,
allowing the user experience to be anticipated (Hollander et al., 20=
21).
In software evaluation, design is crucial for motivation and engagement,
ensuring that end-users feel attracted to using the system (Sutcliffe, 2022=
).
In health profiling, well-designed dashboards enable clearer identification=
of
information, improving the management of healthcare units (Dowding et al=
.,
2015).
=
The aim of
this article is to describe the development of an application for tuberculo=
sis
for the primary care health system in the Basic Health Unit (BHU) in Brazil,
located in the Manguinhos neighborhood, in the =
north
of Rio de Janeiro, place with high rate of TB and low income (O'DWYER et al=
.,
2017). The first stage of research start with a prototype application was
adapted from an App used for COVID-19 (Netto et al., 2021; Netto =
et
al., 2022). The second stage o=
f the
project its design validation in Portugal, where initial usability tests we=
re
carried out Artificial intelligence (IA) validation with Eye Tracking
technology (Hendricks et al., 2021) and a design interface evaluatio=
n by
a group of experts using a heuristic usability assessment (Tripathi et a=
l.,
2019; Nngroup, 2023).
2 METHODOLOGY
The methodological framewor=
k used
was the Design Science Research Methodology (DSRM), which combines the
development of innovative artifacts with the creation of new knowledge (Joh=
annesson
& Perjons, 2021). The main phases of the DS=
R, as
outlined by several authors, typically include: (1) Problem identification;=
(2)
Definition of objectives for the solution; (3) Design and development; (4)
Demonstration; (5) Evaluation; and (6) Communication. Each step of the DSRM=
is
described according to the main authors who address the topic (Vom Brocke, Hevner, & Maedche, 2020). The DSRM
encompasses both stages of the project. However, it was adapted by the auth=
ors
of this article to include a literature review to identify the best practic=
es
in developing an application for TB. The evaluation phase included steps to
assess system usability using eye-tracking and a second stage with a group =
of
experts. Figure 1 summarizes the methodological iterative flow of the resea=
rch
presented in this article.
<= o:p>
<= o:p>
<= o:p>
<= o:p>
<= o:p>
<= o:p>
<= o:p>
Source: Methodology DSR adapted from (Joh=
annesson,
P., Perjons, E., 2021; Vombrocke, J., Hevner, A=
., Maedche,
A., 2020)
Initially, to identify the problem, an
analysis of documents from group meetings with health professionals working=
on
the treatment of tuberculosis was carried out. After that, the goals were
defined to develop a digital solution, including a literature review to
identify the areas of action of TB applications and their results. To better
define the objective of the solution, the tuberculosis treatment process fl=
ows
were identified, obtained from the UBS quality repository, and based on the
Business Process Model (BPM) (Turkman et al., 2019). Finally, the
application was prototyped according to the requirements, based on applicat=
ion
prototyping (Santos, 2021).
After developing a prototype, an evaluati=
on
of the digital application was carried out regarding interface design and
system usability. Initially, usability tests were conducted using IA valida=
tion
with Eye Tracking eye-tracking technology (Hollander et al., 2021; B=
arreto,
2012; Hendricks et al., 2021), enabling the identification of user
feedback through questions clarifying the information on the screen (Alhadreti et al., 2017). This assessment was
conducted at LICA – Applied Communication Research Laboratory from the Scho=
ol
of Social Sciences and Humanities at NOVA University. This session involved=
4
volunteer health professionals from Curry Hospital in Lisbon.
The second part of the validation was car=
ried
out with a group of 6 design experts, students from the Master’s Degree in
Design for Health and Wellbeing from the School of Design and Fine Arts at
Polytechnic of Leiria. They conducted a usability assessment in accordance =
with
the Heuristic Assessment (USA, 2023) and Graphical Interface Assessment
methodology. Heuristic Assessment consists of a usability system review of a
website interface by experts (Nngroup, 2023). T=
he
goal of using experts is to support the quality of software development,
enabling decisions to improve the system or implement a software version and
allocate resources correctly (Tripathi et al., 2019). The evaluation=
of
the graphical interface was conducted according to selected Design Principl=
es
analysis (Lidwell et al., 2010). In the end, the team disseminated t=
he
research through conferences, seminars and scientific publications (Gregori=
o et
al., 2021).
3 RESULTS
AND DISCUSSION
3.1. Problem
Identification
To identify the problems, we evaluated the documents from the discus=
sion
group of health professionals who work with tuberculosis. The document anal=
ysis
revealed that the health unit has a monitoring team with the following task=
s:
(1) identifying and monitoring all TB cases, and (2) filling out a summary
spreadsheet with the TB data collected to deliver reports to the Brazilian
municipal health department. Furthermore, this team also uses the data to
identify alerts of possible cases of treatment abandonment and signs relate=
d to
the responsible family health team. As they are accoun=
Frame
for TB management in the unit, data from different systems are consolidated
into a spreadsheet for control purposes. Frame 1 summarizes each sector's m=
ain
activities, the information collected, and the systems used.
Frame=
1.
Summary of Sectors, Registration of Information and Health Digital Systems =
and
Activities
|
Sectors<=
/b> |
Registration of Information and Systems |
Activities |
|
Care Team |
Paper Records |
Care for patients at the Fiocruz Health
Center, working together with nurses |
|
Monitoring Team |
Planilha de
controle de Tuberculose |
Responsible for monitoring and controlling Tuberculosis at the Bas=
ic
Unity System. |
|
Monitoring Team |
Tuberculosis control spreadsheet |
Responsible for monitoring and controlling Tuberculosis at the Bas=
ic
Unity System. |
|
Laboratory Team |
GAL |
Responsible for executing and controlling the data from the exams
carried out and recording the data in the Management and Laboratory System
(GAL). |
|
Surveillance Team=
|
SINAM |
Responsible for checking the progress of the services provided and
their outcome, recording the data in the National Surveillance System
(SINAM), checking the data, and carrying out analysis |
Source:
Authors (2025).
<= o:p>
In Frame 1 is possible to identify that was the main problem for the management of TB: it is used aa spreadsheet by the monitoring team to consolidate disease information. After that task, the information was uploa= ded or filled in across different Digital Health Systems (E-SUS, SINAM, GAL). <= o:p>
<= o:p>
3.2. Definition=
of
Digital Solution Goals
After analyzing the flow of information and documentation from the TB
group in the UBS, the main "gap" identified for TB information is=
the
distribution of data across different systems. This results in the need to =
use
auxiliary spreadsheets to visualize, monitor, and calculate tuberculosis
indicators. It was identified that the purpose of the application could not=
be
to replace the existing systems, as they are official digital systems from =
the
Brazilian Ministry of Health. However, gaps were identified in the patient
management carried out by health professionals. To better identify possible
solutions, the research team reviewed existing solutions in the scientific
literature to understand what has already been implemented.
3.3. Literature
Review
The literature review used in this article was a scoping review aime=
d at
mapping possible gaps in the studied topic and providing an overview of a
potentially large and diverse body of literature (CORDEIRO & SOARES, 20=
19).
Articles were selected from relevant databases: Scopus, PubMed, Web of Scie=
nce,
and Scielo, using keywords such as "Tuberc=
ulosis
in public health," "TB in public health," "App,"
"Application," "Digital Computing," "Digital
Technology," "Mobile," and "Software." The database
search was conducted in January 2024, and articles up to five years old were
considered. Three independent reviewers specializing in digital health sele=
cted
articles focusing on digital health technologies and their applications for
tuberculosis in public health. The results of these articles are detailed i=
n Frame
2.
Frame
2. Summary of Arti=
cles
|
References |
Article
title |
Digital HealthTechnology |
Country |
Results |
|
<=
span
lang=3DEN-US style=3D'font-family:"Myriad Pro",sans-serif;mso-ansi-langua=
ge:EN-US'>Ali,
Ahmed Osman Ahmed, and Martin H. Prins (2019) |
Mob=
ile
health to improve adherence to tuberculosis treatment in Khartoum state,
Sudan |
Mob=
ile
Health Technology
for DOT using (Short Message Service) SMS |
Sudan |
The
results reducing treatment dropout in TB patients using mobile services |
|
Byonanebye=
et al. (2021) |
“Im=
pact
of a mobile phone-based interactive voice response software on tuberculos=
is
treatment outcomes in Uganda (CFL-TB): a protocol for a randomized contro=
lled
trial” |
Mobile health intervention utilizes interactive
voice response technology |
Uganda |
Ide=
ntified
good results in the use of mobile phones for health systems. |
|
<=
span
lang=3DEN-US style=3D'font-family:"Myriad Pro",sans-serif;mso-ansi-langua=
ge:EN-US'>Navin
et al. (2018) |
“A =
mobile
health intervention to support TB eradication program for adherence to
treatment and a novel QR code-based technique to monitor patient–DOTS
provider interaction |
App
for Smartphone forDirectly observed treatment=
(DOT) |
India |
The=
use
of the App results in better treatment monitoring. |
|
<=
span
lang=3DEN-US style=3D'font-family:"Myriad Pro",sans-serif;mso-ansi-langua=
ge:EN-US'>Park,
Seup, et al (2021) |
“Improving treatment adherence with integrated
patient management for TB patients in Morocco” |
<=
span
lang=3DEN-US style=3D'font-family:"Myriad Pro",sans-serif;mso-ansi-langua=
ge:EN-US'>Mobile
Health Technology for Patient management |
Morocco |
The=
use
of apps was more effective than conventional programs. |
|
<=
span
lang=3DEN-US style=3D'font-family:"Myriad Pro",sans-serif;mso-ansi-langua=
ge:EN-US'>Zhang,
Mengxian, et al. (2023) |
“Di=
gitizing
tuberculosis treatment monitoring in Wuhan city, China, 2020-2021: Impact=
on
medication adherence” |
Electronic
patient Service (E-Pss) Software
for clinical Management |
China |
A h=
igher
success was found |
Source:
Authors (2025).
The studies conducted by various authors
identified advantages in using applications for patients with tuberculosis =
(TB)
(Byonanebye et al., 2021; Park et al<=
/i>.,
2021; Zhang et al., 2023). Zhang et al. (2023) conducted a study in
China between 2020 and 2021, which observed a higher rate of medication
adherence among patients who used applications to support their treatment. =
Park
et al. (2021), in Morocco, observed improvements in the TB management
delivery model through an integrated patient management system with mobile
health technology. Byonanebye et al. (20=
21)
found improvements in TB treatment outcomes with the use of voice-based mob=
ile
applications across five public health units in Uganda. These five selected
studies assisted the research team in identifying different types of
applications used in various countries.
The decision to develop a system will dep=
end
on the gaps identified in the analysis of the current Brazilian TB scenario.
Since the goal of this project is to enhance the management of TB patients =
and
improve patient monitoring and follow-up, it is aligned with the findings of
Zhang et al. (2023). Their study emphasized the urgency of digitalizing TB
treatment information, incorporating digital systems, and using disease
indicators to monitor TB in real-time.
3.4 Design and
Development
To deepen the analysis of the solution and
identify problems, the research team needed to understand the workflow
processes related to health professionals dealing with TB. For this purpose=
, a
documentary analysis of the existing work processes was conducted. This flo=
w is
available on the Fiocruz/ENSP network website.
Analyzing the available flows provided insights into the main activities
carried out by each sector and the processes and systems involved. Figure 2
summarizes the available information.
Figure 2 – Flow of tuberculosis monitoring process=
es
Source: Adapted by the author from the original
process flow.
Figure 2 reveals that the TB care team
provides specialized health services to patients with TB. The primary
activities involve the family health doctor using the E-SUS system to record
patient data. In support of care, a technician from the Fiocruz
laboratory conducts patient exams and seeks better control over necessary
inputs. The laboratory team records results in the Laboratory Environment
Manager (GAL) system of the Brazilian Ministry of Health. Lastly, Epidemiological Surveillance professionals identify =
TB
cases and report them to the Ministry of Health Notification System (SINAM)=
.
By analyzing the activities of each secto=
r,
the process flows in Figure 1, and the information available in Frame 2, the
research team identified the main problems and gathered ideas for prototypi=
ng
the demo. Frame 3 summarizes the distinguished contributions.
Frame
3. Summary of contribution to develop the application demo.
|
Team |
Problem |
Idea |
Prototyping |
Prototyping Item |
|
Care Team |
Quick
identification of patients undergoing TB treatment with their situation.<=
/span> |
Identify
patients with TB in the Application. |
Identify the
groups: Active, Cured, Abandonment, and Exit. |
1 |
|
Monitoring =
Team and
Surveillance Team=
|
They require
the |
Insert data
from the TB control spreadsheet into the application. Build a graph with
Tuberculosis data to visualize the patients’ situation in real time. |
Dashboard w=
ith
TB information |
2 |
Source:
Authors (2025).
In Frame 3, the required systems to imple=
ment
in the application were identified for each team. The analysis identified
control spreadsheets developed by the TB teams, crucial for managing
Tuberculosis data, categorizing patients into the following groups: 1. Acti=
ve
(patients undergoing treatment); 2. Cured; 3. Abandoned (patients who aband=
oned
treatment); and 4. Exit (patients who left the clinic's care). The urgency =
to
centralize data from different spreadsheets and systems used by each user w=
as
also identified as a critical issue to solve. The following requirements we=
re
listed to address the identified problem: 1. Identification of Tuberculosis
Patient Groups; 2. Dashboard with a disease summary.
The first requirement identified in Frame=
3,
Item 1, involves classifying TB patients into groups. These classifications
include: Active TB—patients diagnosed with TB undergoing treatment; Cured
TB—patients who have recovered from TB; TB Abandonment—patients who have
discontinued treatment; and TB Exit—patients transferred to another treatme=
nt
unit or whose diagnosis has changed. In the VigSaúde
application, a column was created for patient classification.
After establishing this field, the simula=
tion
demo began using fictitious TB patient data. On the patient screen within t=
he VigSaúde application, TB patient classifications (Act=
ive,
Cured, Abandonment, and Exit) were incorporated. Each patient was assigned =
to a
specific group, visible in the user group column where an arrow highlights
their respective classification.
Figur=
e 3:
Tuberculosis Summary Chart
Source:
Authors (2025).
3.5 Artifact Demonstration
The prototype of the application was
informally demonstrated to the coordination of the TB management unit. Duri=
ng
this demonstration, some adjustments were requested by these health
professionals regarding the nomenclature used in TB indicators. Overall, the
assessment was satisfactory, particularly due to the capability for quick,
easy, and real-time visualization of information within the health unit.
3.6 Artifact evaluation
After artifact evaluation, two design
evaluations were conducted. The first utilized eye-tracking technology at t=
he
School of Social Sciences and Humanities at NOVA University, followed by the
second at the School of Design and Fine Arts at Polytechnic of Leiria.
3.6.1 Design Evaluation using IA withEye-Tracking
Initial tests were conducted at LICA –
Applied Communication Research Laboratory, where each healthcare profession=
al
was presented with the screen. This session aimed to validate the design by
assessing whether users looked at the correct screen position containing the
requested information. Several tests were performed for each screen of the
application. This article briefly describes the validation of the graphical
screen to illustrate how the research team gathered feedback. The tests
involved asking questions about the displayed information on the screen whi=
le
using software to track the participant's gaze direction.
The following questions were asked on the
graphical screen:
What is the total number of users?
What is the abandonment rate?
What is the age and gender distribution f=
or
18 to 25 years old?
What is the total number of records per
healthcare team?
What is the total number of records by
gender?
During the tests, the Eye-Tracking softwa=
re
tracked participants' gaze directions, enabling the identification of wheth=
er
the location of the requested information matched the question being asked.=
The
results indicated a need for clearer graph captions, especially regarding TB
rates (e.g., "Question 2: What is the abandonment rate?"). It was
observed that participants took longer to direct their gaze to the specific
panel where this information was displayed. Figure 4 illustrates an example=
of
an eye-tracking session.
Figure
4: Tuberculosis Summary Chart, IA with Eye Tracking Evaluating
Source: Aut=
hors
(2025).
3.6.2 Design Evaluation using Expert Group=
The design evaluation was conducted by a group of 6 students from the
Master's in Design for Health and Wellbeing course. Initially, the applicat=
ion
was presented to the students, who then individually validated each screen
using ten principles of software usability (NNGROUP, 2023) – Heuristic
Evaluation. A summary of suggestions for improving the application emerged,
including:
Following
the evaluations, the students remotely presented their results to the Brazi=
lian
development team and discussed each suggested improvement. Subsequently, the
software development team in Brazil implemented the corrections recommended=
by
the Portuguese experts. New tests were then conducted by the developers'
testing team to ensure all corrections were successfully implemented.
4 CONCLUSION
This article outlines the development of a prototype aimed at enhanc=
ing
TB control at a Basic Health Unit (BHU) located in a community with a high
prevalence of this disease in Brazil and a low cure rate. Throughout the
research, a significant reliance on parallel control spreadsheets alongside
existing systems (ESUS-AB, SINAN, GAL) was observed. The results indicate t=
hat
these existing systems alone are insufficient for effective TB control.
Various teams encountered challenges in quickly accessing comprehens=
ive
information, necessitating the use of spreadsheets containing additional da=
ta
not captured by current Ministry of Health systems. Moreover, data
fragmentation posed difficulties in identifying patients undergoing treatme=
nt
and addressing their specific needs. The centralization of data through the=
VigSaúde application facilitated faster and more effe=
ctive
identification of TB patients, including those who abandoned treatment. The
development of this application suggests potential improvements for patient
control systems within Brazil's Primary Health Care (SUS).
The collaboration with Portugal fostered new partnerships between
universities in Brazil and Portugal, enriching capacity and knowledge in He=
alth
Application Design validation. This collaboration also supports the integra=
tion
of new technologies into health application research and educational
institutions in Brazil.
Comparing our findings with those of other authors, we observed that=
TB
applications have a broad scope, benefiting both patients and health
professionals. Similar to findings in the literature (BYONANEBYE et al., 20=
21;
PARK et al., 2021), improvements in disease management were evident. Challe=
nges
in managing information across multiple official systems without seamless
communication were also highlighted (ZHANG et al., 2023); (NETTO et al., 20=
21),
echoing recommendations by the World Health Organization (WHO, 2021) on the=
use
of applications for TB control.
The primary contribution of this research lies in demonstrating the
feasibility of developing applications to enhance disease management.
Centralizing information through an application and visualizing data via a
Dashboard significantly enhances efficiency and information accessibility. =
The
study encountered limitations due to the inability to conduct exhaustive te=
sts
or deploy the application for operational use. Future research should focus=
on
refining the application for improved TB monitoring and control.
Ackno=
wledgments
We wo=
uld
like to express gratitude to LICA – Laboratory for Research in Applied
Communication from ICNOVA / NOVA FCSH for providing access to the eye-track=
ing
equipment used in this study. Special thanks are also due to the CNPq (National Council for Scientific and Technologic=
al
Development) for supporting this research through a postdoctoral grant.
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