An exploration of patient perceptions of adherence to tuberculosis treatment in Tanzania

Implementation bottlenecks of real time medication monitoring (evriMED) for improving adherence to anti-TB drugs among people with tuberculosis in Kilimanjaro, Tanzania

Introduction

Digital Adherence Tools (DATs), which include real-time medication monitoring and Short Message Service (SMS) reminders, have been reported to improve medication adherence among people with Tuberculosis (TB). Recently, in limited resource settings, DATs have been described as a promising tool to monitor patients' medication behaviour. We aimed to determine implementation bottlenecks of real-time medication monitoring using the evriMED device.

Method

We conducted a research study using a mixed-methods approach, involving both people with TB s and directly observed treatment (DOT) providers who participated in the REMIND-TB trial and utilized the evriMED devices. EvriMED is a medication dispenser with internet connectivity that can send real-time SMS reminders. To gather data, we extracted reports from the Wisepill dashboard, specifically the client status report. This report documented the activity status of all devices, including communication and battery status. Additionally, we conducted in-depth interviews with people with TB and TB care providers who were involved in implementing the Remind TB trial in the Kilimanjaro region. These interviews were guided by the MIDI (Measurement Instrument for Determinants of Innovation), which helps identify the factors influencing the implementation of innovations such as evriMED.

Results

Out of the initial 281 participants who were given devices, 245 completed the 6-month follow-up period. The findings indicate that at month 6, most of the devices (49%) reported battery-related challenges. Additionally, forty devices (14%) had reported more than one incidence of losing communication. Through interviews with participants, we observed that evriMED was perceived as user-friendly, and the people with TB reported high satisfaction as the device facilitated improved medication intake. TB care providers also said that evriMED was a relevant tool to be used by the people with TB. However, during the in-depth interview certain implementation bottlenecks were identified, including network issues, limited training, and low technology knowledge among TB care providers, who found the procedure of using the evriMED to be time-consuming.

Conclusion

Implementation of evriMED was perceived as user-friendly and highly satisfactory by people with TB. Certain implementation bottlenecks were identified as potential barriers to the use of devices. These bottlenecks include network issues, limited training, battery-related challenges and low technological knowledge among TB care providers, which may have contributed to communication loss. Further research may be needed to address these limitations and develop effective strategies to facilitate the successful implementation of evriMED as a tool for improving medication intake among people with TB.

Development and validation of a structured questionnaire for assessing risk factors of medication non-adherence among pulmonary tuberculosis patients in Indonesia

Background: Medication non-adherence is a significant concern in tuberculosis (TB) treatment, requiring a precise understanding of the associated risk factors. However, there is a lack of appropriate means to assess the risk factors among TB patients in Indonesia, leading to the development and validation of a structured questionnaire for this purpose. Method: This study unfolded in two distinct phases, namely, the first included questionnaire construction through framework development, item generation, item screening, and pretesting (in 50 patients). The second comprised questionnaire validation with 346 participants using confirmatory factor analysis (CFA) and structural equation modeling-partial least squares (SEM-PLS). Additionally, reliability testing was conducted using Cronbach's alpha and composite reliability statistical techniques. Results: In the development phase, 168 items were defined, consisting of sociodemographic characteristics (8 items) and risk factors for medication non-adherence (160 items). Expert evaluation reduced the number of items to 60, which decreased to 22 after performing a pilot study. Subsequent SEM-PLS modeling resulted in the identification of 14 valid items, representing five major risk factors, namely, socioeconomics (4 items), healthcare team (4 items), condition (3 items), therapy (2 items), and patient (1 item). Only condition-related factors were found to influence non-adherence, and all constructs showed good reliability based on Cronbach's alpha (>0.6) and composite reliability (0.7) values. Conclusion: The final 22 items that emerged from this rigorous process indicated a valid and robust questionnaire for assessing risk factors of medication non-adherence among pulmonary tuberculosis patients in Indonesia. The developed questionnaire was positioned to be a valuable tool for healthcare professionals, policymakers, and scientists in creating patient-centered strategies and interventions to address non-adherence.

What Makes People With Chronic Illnesses Discontinue Treatment? A Practice Theory Informed Analysis of Adherence to Treatment among Patients With Drug-Resistant Tuberculosis in Pakistan

BACKGROUND

Non-adherence to treatment is a frequently observed phenomenon amongst those on long-term treatment for chronic illnesses. This qualitative study draws upon the tenets of 'practice theory' to reveal what shapes patients' ability to adhere to the demanding treatment for drug-resistant tuberculosis (DR-TB) at three treatment sites in Khyber-Pakhtunkhwa (KP) province of Pakistan.

METHODS

This qualitative study involved observation of service provision over a period of nine months of stay at, and embedment within the three treatment sites and in-depth interviews with 13 service providers and 22 patients who became non-adherent to their treatment.

RESULTS

Consistent with the extensive research based on the barriers and facilitator approach, both patients, and providers in our study also talked of patients' doubts about diagnosis and treatment efficacy, side-effects of drugs, economic constraints, unreliable disbursements of monetary incentive, attitude of providers and co-morbidities as reasons for non-adherence to treatment. Applying a practice theory perspective yielded more contextualised insights; inadequate help with patients' physical complaints, unempathetic responses to their queries, and failure to provide essential information, created conditions which hindered the establishment and maintenance of the 'practice' of adhering to treatment. These supply-side gaps created confusion, bred resentment, and exacerbated pre-existing distrust of public health services among patients, and ultimately drove them to disengage with the TB services and stop their treatment.

CONCLUSION

We argue that the lack of supply-side 'responsiveness' to patient needs beyond the provision of a few material inputs is what is lacking in the existing DR-TB program in Pakistan. We conclude that unless Pakistan's TB program explicitly engages with these supply side, system level gaps, patients will continue to struggle to adhere to their treatments and the TB program will continue to lose patients. Conceptually, we make a case for reimagining the act of adherence (or not) to long-term treatment as a 'Practice.'

Factors Associated with Medication Adherence in Elderly Individuals with Tuberculosis: A Qualitative Study

Methods

This qualitative study was conducted in two phases, using an integrative literature review and individual interviews. Studies were gathered without time restriction from MEDLINE databases, Institute for Scientific Information (ISI), Google Scholar, Scopus, and EMBASE, as well as national databases, including Scientific Information Database and Magiran. The findings of 38 studies that met the inclusion criteria were analyzed through the conventional content analysis method based on the ecological approach. After reviewing and forming the data matrix, purposive sampling was performed among healthcare professionals, elderly tuberculosis patients aged 60 and over, and family caregivers of elderly patients to conduct individual interviews. Data obtained from 20 interviews were analyzed using the directed content analysis method. After coding, the data from individual interviews were entered based on similarity and difference in the categories of data matrix obtained from the literature review.

Results

In general, the aforementioned codes were placed in four main categories, including individual factors (i.e., biological factors, affective-emotional factors, behavioral factors, cognitive factors, tuberculosis-related factors, and economic factors), interpersonal factors (i.e., patient's relationship with treatment team and family-related factors), factors related to healthcare service provider centers (i.e., medical centers' facilities and capacity building in healthcare service provider), and extraorganizational factors (i.e., social factors and health policymaking).

Conclusion

The results of this study showed that medication adherence in elderly patients with tuberculosis was a complex and multidimensional phenomenon. Therefore, society, policymakers, and healthcare providers should scrutinize the factors affecting medication adherence in this group of patients to plan and implement more effective interventions.

Prevalence and Retrospective Insight on Tuberculosis in Human Patients in Cross River State, Nigeria; One Health Approach to its Control

Tuberculosis (TB) is a major zoonotic disease of public health importance worldwide. Its burden is more in developing countries due to inadequate surveillance, co-infection with HIV/AIDS and poor social amenities; hence consumption of unpasteurized milk, contaminated meat and inhalation of infected droplets from animals or patients with active TB are the major risk practices. A survey was conducted on TB prevalence from 2013 to 2014 while patients records from TB and Leprosy units of hospitals in the three Agricultural zones (Ogoja, Ikom and Calabar) of Cross River State, Nigeria were assessed from 2000 to 2010. Out of 1,170 sampled patients, 8 (0.7%) were positive, of which 6 and 2 isolates were identified as M. tuberculosis and M. bovis, respectively. Out of 52,558 studied patients files, 235 (0.4%) were positive with varied annual prevalence; the highest (1.0%) and lowest (0.2%) in 2009 and 2011, respectively. The prevalence was higher in dry (0.9% and 0.5%) than the rainy season (0.5% and 0.4%), in females (0.9% and 0.5%) than the males (0.4% and 0.4%) in the survey and retrospective studies, respectively. The age distribution of TB among the patients were; (0% and 0.3%), (0.4% and 0.4%), (0.7% and 0.4%) and (1.5% and 0.7%) for those (≤ 18), (19-40), (41-60) and (> 60) yrs old in the survey and retrospective study, respectively. TB is prevalent in human patients in Cross River State hence, the need for sustainable campaign, continuous surveillance and private/ public health partnership in accurate and early diagnosis, treatment and one health approach to its control.

Development and validation of self-management scale for tuberculosis patients

Background

Tuberculosis remains a major threat to global public health. Regarding its control, directly observed therapy is not suitable as a global strategy for all tuberculosis patients. Self-management may be an important patient-centered tuberculosis case management supplement to directly observed therapy. However, there is currently no well-established instrument for measuring the self-management of tuberculosis patients. This study aimed to develop and validate a self-management scale for tuberculosis patients.

Methods

We developed an initial scale based on the tuberculosis health promotion indicators framework developed by our research group. After item analysis and two rounds of exploratory factor analysis, a final version of the scale was developed. A survey of 462 tuberculosis patients was conducted to develop and validate this scale. Cronbach’s α and intraclass correlation coefficients were used to assess reliability, and Pearson’s correlation coefficients were used to evaluate content validity. Fit indices, convergent validity, and discriminant validity were evaluated using confirmatory factor analysis to determine the construct validity of the scale.

Results

The scale was composed of 17 items in three dimensions (“adherence to treatment behavior,” “transmission prevention behavior,” and “supportive therapy behavior”). These three dimensions explained 76.60% of the variance. Cronbach’s α of the scale was 0.905, and the intraclass correlation coefficient was 0.897. Additionally, Pearson’s correlation analysis showed that each item was strongly correlated with the dimension to which it belonged (r = 0.849–0.915, p < 0.01). Most fit indices (Comparative Fit Index, Normed Fit Index, Incremental Fit Index, Goodness of fit index) reached the recommended threshold, and the average variance extracted values of the three dimensions were higher than 0.5. The values of the square root of the average variance extracted within each dimension were greater than the correlation between dimensions, and all heterotrait–monotrait values were below 0.85.

Conclusions

The self-management scale for tuberculosis patient demonstrated good reliability and validity and could be used as an instrument to evaluate the self-management of patients. Additionally, it could be used to develop evidence-based self-management interventions and evaluate those interventions.

The folk illness kimeo and "traditional" uvulectomy: an ethnomedical study of care seeking for children with cough and weakness in Dar es Salaam

BACKGROUND

Amputation of the uvula by lay providers, so-called "traditional uvulectomy", is common in parts of Sub-Saharan Africa. In Tanzania, the procedure is a treatment of persistent cough, and in some areas of the country, one in three children have been cut. Previous research from Sub-Saharan Africa suggest that uvulectomy by lay providers can increase morbidity and mortality in children, but few studies have examined the cultural ideas and practices that are linked to this form of lay surgery.

METHODS

This ethnomedical study took place in Dar es Salaam. Ten focus group discussions with a total of 43 caregivers in three different administrative districts were carried out, focusing on their perceptions of uvulectomy, the folk illness kimeo, and their experiences with taking a child for cutting. Four folk practitioners who carry out uvulectomies were interviewed individually, with a special focus on their background, and their perceptions of kimeo and uvulectomy.

RESULTS

Caregivers in Dar es Salaam typically take children who suffer from cough, vomiting and weakness to a professional health provider as a first recourse. If the child does not get well relatively quickly, some start fearing that their child may suffer from the folk illness kimeo. Kimeo is perceived by some to be an acute, life-threatening illness that professional health providers are incapable of treating. Folk practitioners treat kimeo by amputating the uvula using forceps. The four interviewed practitioners had learned their skill in apprenticeship, and two of them were third generation uvula cutters. Caregivers regard the folk practitioners as experts who offer a service that is perceived as both efficient and safe.

CONCLUSIONS

Efforts should be made to improve the quality of professional health services for children presenting with cough, including more open communication with caregivers about the folk illness kimeo. More research is needed to establish the clinical conditions that children who are taken for uvulectomy suffer from, to what degree the practice delays professional health care for underlying illnesses like pneumonia, and the negative effects of the cutting itself.

An Adaptable Framework for Factors Contributing to Medication Adherence: Results from a Systematic Review of 102 Conceptual Frameworks

OBJECTIVE

To summarize the available conceptual models for factors contributing to medication adherence based on the World Health Organization (WHO)'s five dimensions of medication adherence via a systematic review, identify the patient groups described in available conceptual models, and present an adaptable conceptual model that describes the factors contributing to medication adherence in the identified patient groups.

METHODS

We searched PubMed®, Embase®, CINAHL®, and PsycINFO® for English language articles published from inception until 31 March 2020. Full-text original publications in English that presented theoretical or conceptual models for factors contributing to medication adherence were included. Studies that presented statistical models were excluded. Two authors independently extracted the data.

RESULTS

We identified 102 conceptual models, and classified the factors contributing to medication adherence using the WHO's five dimensions of medication adherence, namely patient-related, medication-related, condition-related, healthcare system/healthcare provider-related, and socioeconomic factors. Eight patient groups were identified based on age and disease condition. The most universally addressed factors were patient-related factors. Medication-related, condition-related, healthcare system-related, and socioeconomic factors were represented to various extents depending on the patient group. By systematically examining how the WHO's five dimensions of medication adherence were applied differently across the eight different patient groups, we present a conceptual model that can be adapted to summarize the common factors contributing to medication adherence in different patient groups.

CONCLUSION

Our conceptual models can be utilized as a guide for clinicians and researchers in identifying the facilitators and barriers to medication adherence and developing future interventions to improve medication adherence.

PROTOCOL REGISTRATION

PROSPERO Identifier: CRD42020181316.

Effect of Digital Adherence Tools on Adherence to Antiretroviral Treatment Among Adults Living With HIV in Kilimanjaro, Tanzania: A Randomized Controlled Trial

BACKGROUND

Lifelong adherence to antiretroviral treatment remains challenging for people living with HIV (PLHIV). The aim of this study was to investigate whether any of 2 digital adherence tools could improve adherence among PLHIV in Kilimanjaro, Tanzania.

METHODS

We performed a parallel 3-arm, nonblinded, randomized controlled trial with 1:1:1 allocation. We included adults aged between 18 and 65 years, living in Kilimanjaro region, and who were on antiretroviral treatment for at least 6 months. Their adherence, as judged by the study nurses, had to be suboptimal. In one arm, participants received reminder short message service (SMS) texts, followed by a question SMS. In the second arm, participants received a real-time medication monitoring (RTMM) device (Wisepill) with SMS reminders. In the third arm, participants received standard care only. The primary outcome of mean adherence over 48 weeks was compared between arms using between-group t tests in a modified intention-to-treat analysis.

RESULTS

In each arm, we randomized 83 participants: data of 82 participants in the RTMM arm, 80 in the SMS arm, and 81 in the standard care arm were analyzed. The average (over 48 weeks) adherence in the SMS, RTMM, and control arms was 89.6%, 90.6%, and 87.9% for pharmacy refill; 95.9%, 95.0%, and 95.2% for self-report in the past week; and 97.5%, 96.6%, and 96.9% for self-report in the past month, respectively (P values not statistically significant).

CONCLUSIONS

Receiving reminder SMS or RTMM combined with feedback about adherence levels and discussion of strategies to overcome barriers to adherence did not improve adherence to treatment and treatment outcome in PLHIV.

CLINICAL TRIAL NUMBER

PACTR201712002844286.

The Effect of Javanese Language Videos with a Community Based Interactive Approach Method as an Educational Instrument for Knowledge, Perception, and Adherence amongst Tuberculosis Patients

The long period of tuberculosis treatment causes patients to have a high risk of forgetting or stopping the medication altogether, which increases the risk of oral anti-tuberculosis drug resistance. The patient’s knowledge and perception of the disease affect the patient’s adherence to treatment. This research objective was to determine the impact of educational videos in the local language on the level of knowledge, perception, and adherence of tuberculosis patients in the Regional General Hospital (RSUD) Bangil. This quasi-experimental study design with a one-month follow-up allocated 62 respondents in the intervention group and 60 in the control group. The pre- and post-experiment levels of knowledge and perception were measured with a validated set of questions. Adherence was measured by pill counts. The results showed that the intervention increases the level of knowledge of the intervention group higher than that of the control group (p-value < 0.05) and remained high after one month of follow-up. The perceptions domains that changed after education using Javanese (Ngoko) language videos with the Community Based Interactive Approach (CBIA) method were the timeline, personal control, illness coherence, and emotional representations (p-value < 0.05). More than 95% of respondents in the intervention group take 95% of their pill compared to 58% of respondents in the control group (p-value < 0.05). Utilization of the local languages for design a community-based interactive approach to educate and communicate is important and effective.

Insights from participant engagement with the tuberculosis treatment support tools intervention: Thematic analysis of interactive messages to guide refinement to better meet end user needs

BACKGROUND

Tuberculosis (TB) is a largely curable disease, yet it remains one of the top ten causes of death globally. In response to known challenges to completing the long course of TB treatment, our study team developed the TB treatment support tools (TB-TSTs). The mobile application (app) is comprised of the following main components: 1) tracks treatment progress, 2) provides disease tailored information, 3) interactive communication between patients and treatment supporters, and 4) is linked with a direct adherence drug metabolite test.

OBJECTIVE

The objective of this study was to analyze the interactive communication between the patients and the treatment supporter during the TB-TSTs pilot testing to identify issues and guide intervention refinement.

METHODS

We used mixed methods to analyze the interactive communication data. The study was conducted at a pulmonary disease specialized hospital in Argentina. Of the 42 study participants enrolled in the pilot study, 21 were randomly assigned to use the TB-TSTs for 6-months during their TB treatment. The treatment supporter was a registered nurse from the regional level of the National TB program. We conducted thematic and content analysis of the messages in their original language, Spanish. We assessed the themes over time and by whom initiated the messages.

RESULTS

There were 2561 individual messages sent between the participants and treatment supporter. We identified 19 main themes: 7 were participant and 12 were treatment supporter initiated. Participant themes included missed report rationale, arranging in-person meeting, intervention support, TB treatment progress, disease/treatment questions, side effects and additional support. Treatment supporter themes included missed report inquiry, arranging in-person meeting, introduction and instructions, check-in's, positive reinforcement, treatment progress inquiry, test-strip issues, intervention orientation, initial side-effect check in, follow-up on side effects and photo quality issues. Messages and themes decreased over time with most occurring within the first 2 months of treatment.

CONCLUSIONS

Although there was a decrease in the number of messages and the theme types over the 6-month study participation, treatment adherence support remained needed throughout. Potential solutions are suggested for the main issues and recommendations are being used to guide refinement.

Factors influencing oral adherence: qualitative metasummary and triangulation with quantitative evidence

BACKGROUND

Concern about adherence to oral agents among patients with cancer has grown as more oral agents are being used for cancer treatment. Knowledge of common factors that facilitate or inhibit adherence to oral medication regimens can be beneficial to clinicians in identifying patients at risk for nonadherence, in planning care to address barriers to adherence, and in educating patients about ways to improve adherence.

OBJECTIVES

The focus of this review is to synthesize the evidence about factors that influence adherence and identify implications for practice.

METHODS

Literature was searched via PubMed and CINAHL®. Evidence regarding factors influencing adherence was synthesized using a metasummary of qualitative research and triangulated with findings from quantitative research.

FINDINGS

Forty-four factors influencing adherence were identified from 159 research studies of patients with and without cancer. Factors associated with adherence in oncology and non-oncology cases included provider relations, side effects, forgetfulness, beliefs about medication necessity, establishing routines for taking medication, social support, ability to fit medications in lifestyle, cost, and medication knowledge. Among patients with cancer, depression and negative expectations of results also were shown to have a negative relationship to adherence.

Unhealthy behaviour modification, psychological distress, and 1-year survival in cardiac rehabilitation

OBJECTIVE

Cardiac rehabilitation (CR) is considered the recommended secondary prevention treatment for cardiovascular diseases (CVD), in terms of health behaviours and, secondarily, better cardiac outcomes promotion. However, the role of psychiatric and psychosomatic distress on the efficacy of CR is unclear. This research aimed to evaluate the impact of CR on unhealthy behaviour modification and cardiac course, considering the moderating role of depression, anxiety, and psychosomatic syndromes.

DESIGN

A longitudinal design between and within groups was employed. The assessment was repeated four times: at admission to CR (T1), at discharge (T2), 6 (T3) and 12 months following CR completion (T4).

METHOD

One hundred and eight patients undergoing CR versus 85 patients with CVD not referred to CR, underwent psychiatric, psychosomatic, and health behaviour assessment. The assessment included the Structured Clinical Interview for DSM-IV (depression and anxiety), the interview based on Diagnostic Criteria for Psychosomatic Research, GOSPEL Study questionnaire (health behaviours), Pittsburgh Sleep Quality Index, and 8-item Morisky Medication Adherence Scale.

RESULTS

Cardiac rehabilitation was associated with maintenance of physical activity, improvement of behavioural aspects related to food consumption, stress management, and sleep quality. On the contrary, CR was not associated with weight loss, healthy diet, and medication adherence. Depression and psychosomatic syndromes seem to moderate the modification of specific health-related behaviours (physical activity, behavioural aspects of food consumption, stress management, and pharmacological adherence).

CONCLUSION

In CR settings, an integrated assessment including both psychiatric and psychosomatic syndromes is needed to address psychological factors associated with unhealthy behaviour modification. Statement of contribution What is already known on this subject? Cardiac rehabilitation (CR) is considered a class 1A treatment recommendation and the most cost-effective model of secondary prevention to reduce cardiovascular events. There is evidence about the association between psychological distress and both unhealthy behaviour and cardiac course. Depression and psychosomatic distress, such as type A behaviour and demoralization, are frequently associated with CVD course. However, the role of psychiatric and psychosomatic distress in CR is not well known. What does this study add? CR exerted a protective effect on physical activity and a positive effect on eating behaviour, stress management, and quality of sleep. CR did not show any particular effect on smoking, overweight/obesity, dietary habits, medication adherence, and patients' 1-year survival. Findings from this study suggest the importance to consider specific psychological and psychosomatic aspects in affecting lifestyle.

It's complicated: why do tuberculosis patients not initiate or stay adherent to treatment? A qualitative study from South Africa

BACKGROUND

Individuals who test positive for active tuberculosis (TB) but do not initiate treatment present a challenge to TB programmes because they contribute to ongoing transmission within communities. To better understand why individuals do not initiate treatment, or are adherent after initiating treatment, South African respondents were approached to obtain insights as to which factors enabled and inhibited the treatment process.

METHODS

This qualitative work was nested in a larger study investigating initial loss to follow-up (LTFU) amongst new smear positive TB patients across five provinces of South Africa. In-depth interviews were done with 41 adherent and initial LTFU respondents.

RESULTS

Key issues contributing to initial LTFU appeared to be a poor knowledge, or low awareness of TB treatment; stigma around TB including its connection to HIV; immediate problems in the respondents' lives particularly poverty, lack of access to transport and the need to continue working; and problems in the healthcare facilities including under resourced facilities, poor functioning health systems and negative staff attitudes. In contrast the reasons given for being adherent related to the level of illness, support received at home and healthcare facilities, a belief in the health system and positive experiences in the health service including positive attitudes from staff.

CONCLUSIONS

Key changes need to be made to the healthcare system to enable patients to initiate treatment and remain adherent, but the six month regimen of daily observed treatment presents real practical and personal challenges to patients. Alternative strategies to DOTS at facility level should be investigated to bring services closer to communities to encourage patients to access care, initiate and adhere to treatment.

Feasibility of Real Time Medication Monitoring Among HIV Infected and TB Patients in a Resource-Limited Setting

HIV infected and tuberculosis (TB) patients need high levels of treatment adherence to achieve optimal treatment outcomes. We conducted a pilot-study on real time medication monitoring (RTMM) in a resource-limited setting. We enrolled five HIV infected and five TB patients from Kilimanjaro, Tanzania. They took their medication using RTMM. When the device was not opened on time, patients received a reminder SMS. After 3 months, we interviewed patients. Six patients (60 %) reached adherence of >95 %. Nine-hundred-twenty-two of 1104 intakes (84 %) were on time. Five-hundred reminders (45 %) were sent, of which 202 (40 %) were incorrect, because of an unstable mobile network. Nine patients found the device helpful and nine mentioned it keeps medication safe. Six patients reported that the size was too big. Five patients mentioned they received incorrect reminders. The device is considered useful in Kilimanjaro. Optimization of the device should consider network connectivity and the size of the device.

Are free anti-tuberculosis drugs enough? An empirical study from three cities in China

Background

Tuberculosis (TB) patients in China still face a number of barriers in seeking diagnosis and treatment. There is evidence that the economic burden on TB patients and their households discourages treatment compliance.

Methods

A cross-sectional study was conducted in three cities of China. Patients were selected using probability proportional to size (PPS) cluster sampling of rural townships or urban streets, followed by list sampling from a patient register. Data were collected using a questionnaire survey, key informant interviews and focus group discussions with TB patients to gain an understanding of the economic burden of TB and implications of this burden for treatment compliance.

Results

A total of 797 TB patients were surveyed, of which 60 were interviewed in-depth following the survey. More than half had catastrophic health expenditure. TB patients with higher household incomes were less likely to report non-compliance (OR 0.355, 95 % CI 0.140–0.830) and patients who felt that the economic burden relating to TB treatment was high more likely to report non-compliance (OR 3.650, 95 % CI 1.278–12.346). Those who had high costs for transportation, lodging and food were also more likely to report non-compliance (OR 4.150, 95 % CI 1.804–21.999). The findings from the qualitative studies supported those from the survey.

Conclusion

The economic burden associated with seeking diagnosis and treatment remains a barrier for TB patients in China. Reducing the cost of treatment and giving patients subsidies for transportation, lodging and food is likely to improve treatment compliance. Improving doctors’ salary system to cut off the revenue-oriented incentive, and expanding current insurance’s coverage can be helpful to reduce patients’ actual burden or anticipated burden. Future research on this issue is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-015-0080-y) contains supplementary material, which is available to authorized users.

Directly observed therapy for treating tuberculosis

BACKGROUND

Tuberculosis (TB) requires at least six months of treatment. If treatment is incomplete, patients may not be cured and drug resistance may develop. Directly Observed Therapy (DOT) is a specific strategy, endorsed by the World Health Organization, to improve adherence by requiring health workers, community volunteers or family members to observe and record patients taking each dose.

OBJECTIVES

To evaluate DOT compared to self-administered therapy in people on treatment for active TB or on prophylaxis to prevent active disease. We also compared the effects of different forms of DOT.

SEARCH METHODS

We searched the following databases up to 13 January 2015: the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE; EMBASE; LILACS and mRCT. We also checked article reference lists and contacted relevant researchers and organizations.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and quasi-RCTs comparing DOT with routine self-administration of treatment or prophylaxis at home.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias of each included trial and extracted data. We compared interventions using risk ratios (RR) with 95% confidence intervals (CI). We used a random-effects model if meta-analysis was appropriate but heterogeneity present (I(2) statistic > 50%). We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

Eleven trials including 5662 participants met the inclusion criteria. DOT was performed by a range of people (nurses, community health workers, family members or former TB patients) in a variety of settings (clinic, the patient's home or the home of a community volunteer). DOT versus self-administered Six trials from South Africa, Thailand, Taiwan, Pakistan and Australia compared DOT with self-administered therapy for treatment. Trials included DOT at home by family members, community health workers (who were usually supervised); DOT at home by health staff; and DOT at health facilities. TB cure was low with self-administration across all studies (range 41% to 67%), and direct observation did not substantially improve this (RR 1.08, 95% CI 0.91 to 1.27; five trials, 1645 participants, moderate quality evidence). In a subgroup analysis stratified by the frequency of contact between health services in the self-treatment arm, daily DOT may improve TB cure when compared to self-administered treatment where patients in the self-administered group only visited the clinic every month (RR 1.15, 95% CI 1.06 to 1.25; two trials, 900 participants); but with contact in the control becoming more frequent, this small effect was not apparent (every two weeks: RR 0.96, 95% CI 0.83 to 1.12; one trial, 497 participants; every week: RR 0.90, 95% CI 0.68 to 1.21; two trials, 248 participants).Treatment completion showed a similar pattern, ranging from 59% to 78% in the self-treatment groups, and direct observation did not improve this (RR 1.07, 95% CI 0.96 to 1.19; six trials, 1839 participants, moderate quality evidence). DOT at home versus DOT at health facility In four trials that compared DOT at home by family members, or community health workers, with DOT by health workers at a health facility there was little or no difference in cure or treatment completion (cure: RR 1.02, 95% CI 0.88 to 1.18, four trials, 1556 participants, moderate quality evidence; treatment completion: RR 1.04, 95% CI 0.91 to 1.17, three trials, 1029 participants, moderate quality evidence). DOT by family member versus DOT by community health workerTwo trials compared DOT at home by family members with DOT at home by community health workers. There was also little or no difference in cure or treatment completion (cure: RR 1.02, 95% CI 0.86 to 1.21; two trials, 1493 participants, moderate quality evidence; completion: RR 1.05, 95% CI 0.90 to 1.22; two trials, 1493 participants, low quality evidence). Specific patient categoriesA trial of 300 intravenous drug users in the USA evaluated direct observation with no observation in TB prophylaxis to prevent active disease and showed little difference in treatment completion (RR 1.00, 95% CI 0.88 to 1.13; one trial, 300 participants, low quality evidence).

AUTHORS' CONCLUSIONS

From the existing trials, DOT did not provide a solution to poor adherence in TB treatment. Given the large resource and cost implications of DOT, policy makers might want to reconsider strategies that depend on direct observation. Other options might take into account financial and logistical barriers to care; approaches that motivate patients and staff; and defaulter follow-up.

Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey

BACKGROUND

Surgical care is increasingly recognised as an important part of global health yet data for the burden of surgical disease are scarce. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) was developed to measure the prevalence of surgical conditions and surgically treatable deaths in low-income and middle-income countries. We administered this survey countrywide in Sierra Leone, which ranks 180 of the 187 nations on the UN Development Index.

METHODS

The study was done between Jan 9 and Feb 3, 2012. 75 of 9671 enumeration areas, the smallest administrative units in Sierra Leone, were randomly selected for the study clusters, with a probability proportional to the population size. In each cluster 25 households were randomly selected to take part in the survey. Data were collected via handheld tablets by trained local medical and nursing students. A household representative was interviewed to establish the number of household members (defined as those who ate from the same pot and slept in the same structure the night before the interview), identify deaths in the household during the previous year, and establish whether any of the deceased household members had a condition needing surgery in the week before death. Two randomly selected household members underwent a head-to-toe verbal examination and need for surgical care was recorded on the basis of the response to whether they had a condition that they believed needed surgical assessment or care.

FINDINGS

Of the 1875 targeted households, data were analysed for 1843 (98%). 896 of 3645 (25%; 95% CI 22·9-26·2) respondents reported a surgical condition needing attention and 179 of 709 (25%; 95% CI 22·5-27·9) deaths of household members in the previous year might have been averted by timely surgical care.

INTERPRETATION

Our results show a large unmet need for surgical consultations in Sierra Leone and provide a baseline against which future surgical programmes can be measured. Additional surveys in other low-income and middle-income countries are needed to document and confirm what seems to be a neglected component of global health.

FUNDING

Surgeons OverSeas, Thompson Family Foundation.