# Shesha, a WhatsApp Chatbot for Linking Household Contacts to Tuberculosis Treatment or Preventive Therapy in South Africa: Design and Development

## TL;DR

Shesha is a WhatsApp chatbot designed to help South African households connect to tuberculosis treatment or preventive therapy, using design thinking and health behavior models.

## Contribution

The paper introduces Shesha, a novel WhatsApp-based chatbot addressing TB linkage to care through design thinking and the Health Belief Model.

## Key findings

- Shesha was successfully developed and launched in September 2023 to support TB testing and preventive treatment linkage.
- Early user feedback showed appreciation for TB-related information but highlighted the need for ongoing engagement to improve care linkage.
- The design thinking framework and Health Belief Model were effectively used to align the chatbot with user needs and public health goals.

## Abstract

Literature on the development of mobile health (mHealth) tools for public health interventions is scarce. This scarcity creates a knowledge gap, and new tools may repeat the mistakes of past implementations.

In this paper, we describe the development of Shesha, a WhatsApp-based chatbot designed to facilitate linkage to care for household contacts of people being treated for tuberculosis (TB). Shesha facilitates linkage by providing TB test results, TB preventive treatment (TPT) information, nudges, reminders, and personalized support. We developed Shesha to address the human resource capacity challenges posed by South Africa’s new universal TB testing and TPT policies.

We applied a design thinking framework with 7 phases: empathize, discover, define, prototype, build and launch, improve, and evaluate. The process started with gathering insights from TB contact tracing studies and consulting with global and local experts to address the challenges of universal TB testing and TPT. Based on these findings, we defined the core functionalities of Shesha and incorporated them in the Health Belief Model to encourage health-seeking behavior. In collaboration with the developers, we developed the WhatsApp-based chatbot. We selected WhatsApp for its wide accessibility and user-friendliness.

We successfully developed and launched the Shesha in September 2023, with implementation expected to continue until March 2025. Early user acceptance revealed that users generally valued the information provided on the tool regarding TB and TPT; however, they required ongoing engagement to link to care. Ongoing evaluations, guided by the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework, will assess the tool’s impact on reducing community health worker workloads and improving linkage to care.

Documenting the development of mHealth technologies is crucial for guiding future projects and improving health interventions. In our study, frameworks like design thinking and the Health Belief Model aligned Shesha with user needs and programmatic goals. Comprehensive documentation may help assess the chatbot’s performance and guide future improvements, supporting scalability and efficiency in mHealth interventions across public health settings.