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BMJ Open. 2019 May 9;9(5):e028073. doi: 10.1136/bmjopen-2018-028073.

Perceptions of drones, digital adherence monitoring technologies and educational videos for tuberculosis control in remote Madagascar: a mixed-method study protocol.

Author information

School of Health Studies, Western University, London, Ontario, Canada.
Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Basel-Stadt, Switzerland.
Mycobacteria Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar.
Global Health Institute, Stony Brook University, Stony Brook, New York, NY, USA.
Health Department, Center Valbio, Ranomafana, Madagascar.
Immunopathology, Centre de recherche du CHUM, Montreal, Quebec, Canada.
Microbiology, Infectious Diseases and Immunology, Université de Montréal, Montréal, Québec, Canada.



Poor road and communication infrastructure pose major challenges to tuberculosis (TB) control in many regions of the world. TB surveillance and patient support often fall to community health workers (CHWs) who may lack the time or knowledge needed for this work. To meet the End TB Strategy goal of reducing TB incidence by 90% by 2035, the WHO calls for intensified research and innovation including the rapid uptake of new tools, interventions and strategies. Technologies that 'leapfrog' infrastructure challenges and support CHWs in TB control responsibilities have the potential to dramatically change TB outcomes in remote regions. Such technologies may strengthen TB control activities within challenged national tuberculosis treatment and control programmes (NTPs), and be adapted to address other public health challenges. The deployment of innovative technologies needs to be differentially adapted to context-specific factors. The Drone Observed Therapy System (DrOTS) project was launched in Madagascar in 2017 and integrates a bundle of innovative technologies including drones, digital adherence monitoring technology and mobile device-based educational videos to support TB control.


This mixed-methods study gathers and analyses cultural perceptions of the DrOTS project among key stakeholders: patients, community members, CHWs, village chiefs and NTP-DrOTS mobile health teams. Data from questionnaires, semistructured interviews, focus group discussions (FGD) and ethnographic observation gathered from June 2018 to June 2019 are thematically analysed and compared to identify patterns and singularities in how DrOTS stakeholders perceive and interact with DrOTS technologies, its enrolment processes, objectives and team.


Ethics approval was obtained from the National Bioethics Research Committee of Madagascar and Stony Brook University institutional review board. Study results will be submitted for peer-reviewed publication. In Madagascar, results will be presented in person to Ministry and other Malagasy decision-makers through the Institut Pasteur de Madagascar.


This study is designed to foreground the voices of patients and potential patients in the DrOTS programme. CHW participants in this study also supported the design of study information sessions and recruitment strategies. One member of the mobile health team provided detailed input on the wording and content of FGD and interview guides. Study findings will be presented via a report in French and Malagasy to CHW, mobile health team and other village-level participants who have email/internet access.


Madagascar; biomedical technology; drones; global health; medication adherence; tuberculosis

Conflict of interest statement

Competing interests: Authors declare no financial or personal relationships with other people or organisations that could inappropriately influence this work. The authors have no relationship and obtained no funding for this study from the developers of evriMEDTM. The first and corresponding author had full access to all the data in the study and had final responsibility for the decision to submit this work for publication.

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