Assessment of Directly Observed Therapy (DOT) following tuberculosis regimen change in Addis Ababa, Ethiopia: a qualitative study

Feasibility and acceptability of the smart pillbox and medication label with differentiated care to support person-centered tuberculosis care among ASCENT trial participants - A multicountry study

Introduction

Digital adherence technologies (DATs) can offer alternative approaches to support tuberculosis treatment medication adherence. Evidence on their feasibility and acceptability in high TB burden settings is limited. We conducted a cross-sectional survey among adults with drug-sensitive tuberculosis (DS-TB), participating in pragmatic cluster-randomized trials for the Adherence Support Coalition to End TB project in Ethiopia (PACTR202008776694999), the Philippines, South Africa and Tanzania (ISRCTN 17706019).

Methods

From each country we selected 10 health facilities implementing the DAT intervention (smart pillbox or medication labels, with differentiated care support), ensuring inclusion of urban/rural and public/private facilities. Adults on DS-TB regimen using a DAT were randomly selected from each facility. Feasibility of the DATs was assessed using a standardized tool. Acceptability was measured using a 5-point Likert-scale, using the Capability, Opportunity, Motivation, Behavior (COM-B) model. Mean scores of Likert-scale responses within each COM-B category were estimated, adjusted for facility-level clustering. Data were summarized by country and DAT type.

Results

Participants using either the pillbox (n = 210) or labels (n = 169) were surveyed. Among pillbox users, phone ownership (79%), use of pillbox reminders (87%) and taking treatment without the pillbox (22%) varied by country. Among label users, phone ownership (81%), paying extra to use the labels (8%) and taking treatment without using labels (41%) varied by country. Poor network, problems with phone charging and access, not having the pillbox and forgetting to send text were reasons for not using DATs. Overall, people with TB had a favorable impression of both DATs, with mean composite scores between 4·21 to 4·42 across COM-B categories. Some disclosure concerns were reported.

Conclusion

From client-perspective, pillboxes and medication labels with differentiated care support were feasible to implement and acceptable in variety of settings. However, implementation challenges related to network, phone access, stigma, additional costs to people with TB to use DATs need to be addressed.

Digital Health Interventions to Enhance Tuberculosis Treatment Adherence: Scoping Review

Background

Digital health technologies are widely used for disease management, with their computing platforms, software, and sensors being used for health care. These technologies are developed to manage chronic diseases and infectious bacterial diseases, including tuberculosis (TB).

Objective

This study aims to comprehensively review the literature on the use of digital health interventions (DHIs) for enhancing TB treatment adherence and identify major strategies for their adoption.

Methods

We conducted a literature search in the PubMed, Cochrane Library, Ovid Embase, and Scopus databases for relevant studies published between January 2012 and March 2022. Studies that focused on web-based or mobile phone-based interventions, medication adherence, digital health, randomized controlled trials, digital interventions, or mobile health and ubiquitous health technology for TB treatment and related health outcomes were included.

Results

We identified 27 relevant studies and classified them according to the intervention method, a significant difference in treatment success, and health outcomes. The following interventions were emphasized: SMS text messaging interventions (8/27, 30%), medicine reminders (6/27, 22%), and web-based direct observation therapy (9/27, 33%). Digital health technology significantly promoted disease management among individuals and health care professionals. However, only a few studies addressed 2-way communication therapies, such as interactive SMS text messaging and feedback systems.

Conclusions

This scoping review classified studies on DHIs for patients with TB and demonstrated their potential for the self-management of TB. DHIs are still being developed, and evidence on the impact of digital technologies on enhancing TB treatment adherence remains limited. However, it is necessary to encourage patients' participation in TB treatment and self-management through bidirectional communication. We emphasize the importance of developing a communication system.

Determinants of Unsuccessful TB Treatment Outcomes Among Patients on Directly Observed Treatment Short Course in Jimma Town Health Facilities, Southwest Ethiopia: A Case-Control Study

Background

Even though Ethiopia's Federal Ministry of Health has been implementing several programs aimed at reducing the burden of tuberculosis (TB), It does not demonstrate adequate progress. As a result, identifying the determinants of unsuccessful outcomes of directly observed treatment, short-course (DOTS) is critical.

Purpose

This study aimed to assess the determinants of unsuccessful TB treatment outcomes among patients with DOTS in Jimma town, southwest Ethiopia.

Patients and Methods

An unmatched case-control study using secondary data was conducted among 118 cases and 472 controls from April 1 to June 1, 2021. Cases were TB cases with unsuccessful treatment courses whereas controls were those of successful treatment. Data were collected using a standardized tool. Statistical analysis was done using SPSS version 23 software. A binary logistic regression model was used to identify the determinants.

Results

We found that the determinants including age > 35 years (AOR=1.9, 95% CI: 1.14-3.2), lack of contact person (AOR= 27, 95% CI: 15.8-46.3), being HIV positive (AOR=7.3, 95% CI: 3.7-14.2)), and being malnourished (AOR=4.5, 95% CI: 1.5-12.9) were significantly associated with unsuccessful tuberculosis treatment outcome.

Conclusion

In this study, advanced age, being HIV positive, lack of contact person, and being malnourished were determinant factors for unsuccessful TB treatment outcomes. Hence, careful monitoring, screening, and management of risk factors are recommended.

Cost of treatment support for multidrug-resistant tuberculosis using patient-centred approaches in Ethiopia: a model-based method

BACKGROUND

Patient and health system costs for treating multidrug-resistant tuberculosis (MDR-TB) remain high even after treatment duration was shortened. Many patients do not finish treatment, contributing to increased transmission and antimicrobial resistance. A restructure of health services, that is more patient-centred has the potential to reduce costs and increase trust and patient satisfaction. The aim of the study is to investigate how costs would change in the delivery of MDR-TB care in Ethiopia under patient-centred and hybrid approaches compared to the current standard-of-care.

METHODS

We used published data, collected from 2017 to 2020 as part of the Standard Treatment Regimen of Anti-Tuberculosis Drugs for Patients with MDR-TB (STREAM) trial, to populate a discrete event simulation (DES) model. The model was developed to represent the key characteristics of patients' clinical pathways following each of the three treatment delivery strategies. To the pathways of 1000 patients generated by the DES model we applied relevant patient cost data derived from the STREAM trial. Costs are calculated for treating patients using a 9-month MDR-TB treatment and are presented in 2021 United States dollars (USD).

RESULTS

The patient-centred and hybrid strategies are less costly than the standard-of-care, from both a health system (by USD 219 for patient-centred and USD 276 for the hybrid strategy) and patient perspective when patients do not have a guardian (by USD 389 for patient-centred and USD 152 for the hybrid strategy). Changes in indirect costs, staff costs, transport costs, inpatient stay costs or changes in directly-observed-treatment frequency or hospitalisation duration for standard-of-care did not change our results.

CONCLUSION

Our findings show that patient-centred and hybrid strategies for delivering MDR-TB treatment cost less than standard-of-care and provide critical evidence that there is scope for such strategies to be implemented in routine care. These results should be used inform country-level decisions on how MDR-TB is delivered and also the design of future implementation trials.

Comparing adherence to MDR-TB treatment among patients on self-administered therapy and those on directly observed therapy: non-inferiority randomized controlled trial

BACKGROUND

Adherence is key to the treatment success of multi-drug resistant tuberculosis (MDR-TB) and prevention of community transmission. Directly observed therapy (DOT) is the recommended approach for the management of patients with MDR-TB. Uganda implements a health facility-based DOT approach where all patients diagnosed with MDR-TB report to the nearest private or public health facility for daily observation of ingesting their medicines by a health care provider. Directly observed therapy is very costly for both the patient and health care system. It follows the assumption that MDR TB patients have a history of poor adherence to TB treatment. But only 21% of MDR-TB patients notified globally and 1.4-12% notified in Uganda had been previously treated for TB. The shift to all oral treatment regimen for MDR-TB provides an opportunity for the exploration of self-administered therapy for this group of patients even with use of remotely operated adherence technology. We are conducting a non-inferiority open-label randomized controlled trial to compare adherence to MDR-TB treatment among patients on self-administered therapy (measured by Medication Events Monitoring System (MEMS) technology) with a control group on DOT.

METHODS

We plan to enrol 164 newly diagnosed MDR-TB patients aged ≥ 8 years from three regional hospitals based in rural and urban Uganda. Patients with conditions that affect their dexterity and ability to operate the MEMS-operated medicine equipment will not be eligible to participate in the trial. Patients are randomized to either of the two study arms: self-administered therapy with adherence being monitored using MEMS technology (intervention arm) or health facility-based DOT (control arm) and will be followed up monthly. Adherence is measured by the number of days the medicine bottle is open to access medication as recorded by the MEMS software in the intervention arm and treatment complaint days as recorded in the TB treatment card in the control arm. The primary outcome is the comparison of adherence rates between the two study arms.

DISCUSSION

The evaluation of self-administered therapy for patients with MDR-TB is important to inform cost-effective management strategies for these patients. The approval of all oral regimens for the treatment of MDR-TB provides an opportunity for innovations such as MEMS technology to support sustainable options for MDR-TB treatment adherence support in low-resource settings.

TRIAL REGISTRATION

Pan African Clinical Trials Registry, Cochrane #PACTR202205876377808. Retrospectively registered on 13 May 2022.

Stakeholders' perspective on the daily regimen of tuberculosis treatment- A qualitative approach

INTRODUCTION

In the context of changing over from an intermittent treatment regimen to a daily regimen, it becomes crucial to understand the impact of a daily regimen on the treatment process and outcome. It enables health professionals to strengthen strategies, to enhance the quality of treatment as well as the quality of life of TB patients. The perspective of each stakeholder involved in the process is important in assessing the impact of the daily regimen.

OBJECTIVES

To understand patients' and providers' perspectives on the daily regimen of Tuberculosis treatment.

METHODOLOGY

A qualitative study was conducted between March 2020 to June 2020, including in-depth interviews with TB patients on treatment and DOT providers, and Key Informant Interview(KII) with TB Health Visitors(TBHV) and family members of TB patients. A thematic-network analysis approach was utilized to get the results.

RESULTS

Two sub-themes emerged: (i) Acceptance of the daily regimen of treatment; (ii) operational difficulties of the daily regimen. No injections in the regimen, fewer side effects of drugs as dose depends on weight band, family members can be treatment supporter, awareness about disease and treatment, the drugs are as same as private drugs available, adherence has improved, monthly DBT were found to some of the enablers in the study. The Barriers found in the study were traveling daily to get drugs, loss of daily wages, accompanying patients daily, tracing private patients, pyridoxine is not given free in this regimen, increased workload for treatment providers, etc. CONCLUSION: The study points out that acceptance of the patient to the daily regimen is better as they have lesser side effects. The operational difficulties in the implementation of the daily regimen can be addressed by providing family members as treatment supporters.

Design, development, and testing of a voice-text mobile health application to support Tuberculosis medication adherence in Uganda

Background

Tuberculosis (TB) continues to persist with a high disease burden globally. Non-adherence to treatment remains a major problem to TB control. In Uganda, one in every four TB patients does not adhere to their TB medication. The purpose of this study was to design, develop and assess implementation of a voice-text-based mobile application to support TB patients’ adherence to medication.

Methods

Design science research methodology (DSRM) was utilized to develop a voice-text-based mobile health application. Agile software methodology was used to achieve steps of DSRM that are; design and development. Focus group discussions (FGDs) and Key informant interviews (KIIs) were conducted and data analysed using thematic content analysis.

Results

During problem identification, Stigma, transport costs, being asymptomatic, drug side effects, lack of family support were identified as challenges affecting adherence. Technologies identified and used for the development of the voice-text application included; extensible mark-up language (XML) File, Apache server, Ubuntu Server, Hypertext Pre-processor, and jQuery. In the pilot study, 27 voice messages were broadcasted, 85.2% were delivered, 103 text messages were sent and 92.2% were delivered to the intended recipients.

Conclusions

Voice-text message mobile health application can be used to reach a wider patient population and it has the capability of addressing some of the challenges affecting TB medication adherence.

Protocol of a parallel group Randomized Control Trial (RCT) for Mobile-assisted Medication Adherence Support (Ma-MAS) intervention among Tuberculosis patients

BACKGROUND

Non-adherence to Tuberculosis (TB) medication is a serious threat to TB prevention and control programs, especially in resource-limited settings. The growth of the popularity of mobile phones provides opportunities to address non-adherence, by facilitating direct communication more frequently between healthcare providers and patients through SMS texts and voice phone calls. However, the existing evidence is inconsistent about the effect of SMS interventions on TB treatment adherence. Such interventions are also seldom developed based on appropriate theoretical foundations. Therefore, there is a reason to approach this problem more rigorously, by developing the intervention systematically with evidence-based theory and conducting the trial with strong measurement methods.

METHODS

This study is a single-blind parallel-group design individual randomized control trial. A total of 186 participants (93 per group) will be individually randomized into one of the two groups with a 1:1 allocation ratio by a computer-generated algorithm. Group one (intervention) participants will receive daily SMS texts and weekly phone calls concerning their daily medication intake and medication refill clinic visit reminder and group two (control) participants will receive the same routine standard treatment care as the intervention group, but no SMS text and phone calls. All participants will be followed for two months of home-based self-administered medication during the continuation phases of the standard treatment period. Urine test for the presence of isoniazid (INH) drug metabolites in urine will be undertaken at the random point at the fourth and eighth weeks of intervention to measure medication adherence. Medication adherence will also be assessed by self-report measurements using the AIDS Clinical Trial Group adherence (ACTG) and Visual Analogue Scales (VAS) questionnaires, and clinic appointment attendance registration. Multivariable regression model analysis will be employed to assess the effect of the Ma-MAS intervention at a significance level of P-value < 0.05 with a 95% confidence interval.

DISCUSSION

For this trial, a mobile-assisted medication adherence intervention will first be developed systematically based on the Medical Research Council framework using appropriate behavioural theory and evidence. The trial will then evaluate the effect of SMS texts and phone calls on TB medication adherence. Evidence generated from this trial will be highly valuable for policymakers, program managers, and healthcare providers working in Ethiopia and beyond.

TRIAL REGISTRATION

The trial is registered in the Pan-Africa Clinical Trials Registry with trial number PACTR202002831201865.

Evaluation of implementation and effectiveness of digital adherence technology with differentiated care to support tuberculosis treatment adherence and improve treatment outcomes in Ethiopia: a study protocol for a cluster randomised trial

Background

Digital adherence technologies (DATs) are recommended to support patient-centred, differentiated care to improve tuberculosis (TB) treatment outcomes, but evidence that such technologies improve adherence is limited. We aim to implement and evaluate the effectiveness of smart pillboxes and medication labels linked to an adherence data platform, to create a differentiated care response to patient adherence and improve TB care among adult pulmonary TB participants. Our study is part of the Adherence Support Coalition to End TB (ASCENT) project in Ethiopia.

Methods/Design

We will conduct a pragmatic three-arm cluster-randomised trial with 78 health facilities in two regions in Ethiopia. Facilities are randomised (1:1:1) to either of the two intervention arms or standard of care. Adults aged ≥ 18 years with drug-sensitive (DS) pulmonary TB are enrolled over 12 months and followed-up for 12 months after treatment initiation. Participants in facilities randomised to either of the two intervention arms are offered a DAT linked to the web-based ASCENT adherence platform for daily adherence monitoring and differentiated response to patient adherence for those who have missed doses. Participants at standard of care facilities receive routine care. For those that had bacteriologically confirmed TB at treatment initiation and can produce sputum without induction, sputum culture will be performed approximately 6 months after the end of treatment to measure disease recurrence. The primary endpoint is a composite unfavourable outcome measured over 12 months from TB treatment initiation defined as either poor end of treatment outcome (lost to follow-up, death, or treatment failure) or treatment recurrence measured 6 months after the scheduled end of treatment. This study will also evaluate the effectiveness, feasibility, and cost-effectiveness of DAT systems for DS-TB patients.

Discussion

This trial will evaluate the impact and contextual factors of medication label and smart pillbox with a differentiated response to patient care, among adult pulmonary DS-TB participants in Ethiopia. If successful, this evaluation will generate valuable evidence via a shared evaluation framework for optimal use and scale-up.

Trial registration: Pan African Clinical Trials Registry PACTR202008776694999, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12241, registered on August 11, 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06833-x.

Adherence to TB treatment remains low during continuation phase among adult patients in Northwest Ethiopia

BACKGROUND

Patients' failure to adhere to TB treatment was a major challenge that leads to poor treatment outcomes. In Ethiopia, TB treatment success was low as compared with the global threshold. Despite various studies done in TB treatment adherence, little was known specifically in continuation phase where TB treatment is mainly patient-centered. This study aimed to determine adherence to TB treatment and its determinants among adult patients during continuation phase.

METHODS

We deployed a facility-based cross-sectional study design supplemented with qualitative data to explore perspectives of focal healthcare providers. The study population was all adult (≥18 years) TB patients enrolled in the continuation phase and focal healthcare workers in TB clinics. The study included 307 TB patients from 22 health facilities and nine TB focal healthcare providers purposively selected as key-informant. A short (11 questions) version Adherence to Refill and Medication Scale (ARMS) was used for measuring adherence. Data was collected using an interviewer-administered questionnaire and in-depth interview for qualitative data. Binary logistic regression was applied to identify factors associated with patient adherence. We followed a thematic analysis for the qualitative data. The audio data was transcribed, coded and categorized into themes using OpenCode software.

RESULTS

Among 307 participants, 64.2% (95% CI (58.6-69.4%) were adherent to TB treatment during continuation phase. A multi-variable analysis shown that secondary education (AOR = 4.138, 95% CI; 1.594-10.74); good provider-patient relationship (AOR = 1.863, 95% CI; 1.014-3.423); good knowledge on TB treatment (AOR = 1.845, 95% CI; 1.012-3.362) and middle family wealth (AOR = 2.646, 95% CI; 1.360-5.148) were significantly associated with adherence to TB treatment. The majority (58%) of patients mentioned forgetfulness, and followed by 17.3% of them traveling away from home without pills as major reasons for non-adherence to TB treatment.

CONCLUSIONS

The study indicated that patients' adherence to TB treatment remains low during continuation phase. The patient's education level, knowledge, family wealth, and provider-patient relationship were found positively associated with patient adherence. Forgetfulness, traveling away, and feeling sick were major reasons for non-adherence to TB treatment. Interventional studies are needed on those factors to improve patient adherence to TB treatment during continuation phase.

Effect of a phone reminder system on patient-centered tuberculosis treatment adherence among adults in Northwest Ethiopia: a randomised controlled trial

OBJECTIVES

This study aimed to evaluate the effect of the phone reminder system on patient-centred TB treatment adherence during continuation phase, where patients are responsible for taking medication at home.

METHODS

We conducted a two-arm randomised controlled trial on adult patients with TB during the continuation phase. In the intervention arm, patients received routine care plus phone-based weekly pill refilling and daily medication reminders. In the control arm, participants received only routine care. A covariate adaptive randomisation technique was used to balance covariates during allocation. The primary outcome was adherence to patient-centred TB treatment, and secondary outcomes included provider-patient relationship and treatment outcomes. We applied per-protocol and intention-to-treat analysis techniques.

RESULTS

We randomised 306 patients to intervention (n=152) and control (n=154) groups. Adherence to patient-centred TB treatment was 79% (110/139) in intervention and 66.4% (95/143) in control groups, with relative risk (RR) (95% lower CI) (RR=1.632 (1.162 to ∞); p=0.018, one tailed). Good provider-patient relationship was 73.3% (102/139) in intervention group and 52.4% (75/143) in control group, p=0.0001. TB treatment success was 89.5% (136/152) in intervention group and 85.1% (131/154) in control group, p=0.1238.

CONCLUSIONS

Mobile phone-based weekly refilling with daily medication reminder system improved adherence to patient-centred TB treatment and provider-patient relationship; however, there was no significant effect on treatment success.

TRIAL REGISTRATION NUMBER

Pan African Clinical Trials Registry (PACTR201901552202539).

Assessing private provider perceptions and the acceptability of video observed treatment technology for tuberculosis treatment adherence in three cities across Viet Nam

Background

The World Health Organization recently recommended Video Observed Therapy (VOT) as one option for monitoring tuberculosis (TB) treatment adherence. There is evidence that private sector TB treatment has substandard treatment follow-up, which could be improved using VOT. However, acceptability of VOT in the private sector has not yet been evaluated.

Methods

We conducted a cross-sectional survey employing a theoretical framework for healthcare intervention acceptability to measure private provider perceptions of VOT across seven constructs in three cities of Viet Nam: Ha Noi, Ho Chi Minh City, and Hai Phong. We investigated the differences in private providers’ attitudes and perceptions of VOT using mixed ordinal models to test for significant differences in responses between groups of providers stratified by their willingness to use VOT.

Results

A total of 79 private providers completed the survey. Sixty-two providers (75%) indicated they would use VOT if given the opportunity. Between private providers who would and would not use VOT, there were statistically significant differences (p≤0.001) in the providers’ beliefs that VOT would help identify side effects faster and in their confidence to monitor treatment and provide differentiated care with VOT. There were also significant differences in providers’ beliefs that VOT would save them time and money, address problems faced by their patients, benefit their practice and patients, and be relevant for all their patients.

Conclusion

Private providers who completed the survey have positive views towards using VOT and specific subpopulations acknowledge the value of integrating VOT into their practice. Future VOT implementation in the private sector should focus on emphasizing the benefits and relevance of VOT during recruitment and provide programmatic support for implementing differentiated care with the technology.

"You have to change your whole life": A qualitative study of the dynamics of treatment adherence among adults with tuberculosis in the United Kingdom

Maintaining adherence to treatment for tuberculosis (TB) is essential if the disease is to be eliminated. As part of formative research to develop an intervention to improve adherence, we documented the lived experiences of adults receiving anti-TB treatment (ATT) in three UK cities and examined how personal, social, and structural circumstances interacted to impact on individuals’ adherence to treatment. Using a topic guide that explored social circumstances and experiences of TB care, we conducted in-depth interviews with 18 adults (six women) who were being or had been treated for TB (patients) and four adults (all women) who were caring for a friend, relative, or partner being treated for TB (caregivers). We analysed transcripts using an adapted framework method that classified factors affecting adherence as personal, social, structural, health systems, or treatment-related. Eleven of 18 patients were born outside the UK (in South, Central, and East Asia, and Eastern and Southern Africa); among the seven who were UK-born, four were Black, Asian, or Minority Ethnic and three were White British. TB and its treatment were often disruptive: in addition to debilitating symptoms and side effects of ATT, participants faced job insecurity, unstable housing, stigma, social isolation, worsening mental health, and damaged relationships. Those who had a strong support network, stable employment, a routine that could easily be adapted, a trusting relationship with their TB team, and clear understanding of the need for treatment reported finding it easier to adhere to ATT. Changes in circumstances sometimes had dramatic effects on an individual’s ability to take ATT; participants described how the impact of certain acute events (e.g., the onset of side effects or fatigue, episodes of stigmatisation, loss of income) were amplified by their timing or through their interaction with other elements of the individual’s life. We suggest that the dynamic and fluctuating nature of these factors necessitates comprehensive and regular review of needs and potential problems, conducted before and during ATT; this, coupled with supportive measures that consider (and seek to mitigate) the influence of social and structural factors, may help improve adherence.

Study protocol and implementation details for a pragmatic, stepped-wedge cluster randomised trial of a digital adherence technology to facilitate tuberculosis treatment completion

INTRODUCTION

Low-cost digital adherence technologies (DATs) such as 99DOTS have emerged as an alternative to directly observed therapy (DOT), the current standard for tuberculosis (TB) treatment supervision. However, there are limited data to support DAT scale-up. The 'DOT to DAT' trial aims to evaluate the effectiveness and implementation of a 99DOTS-based TB treatment supervision strategy.

METHODS AND ANALYSIS

This is a pragmatic, stepped-wedge cluster randomised trial, with hybrid type 2 effectiveness-implementation design. The trial will include all adults (estimated N=1890) treated for drug-susceptible pulmonary TB over an 8-month period at 18 TB treatment units in Uganda. Three sites per month will switch from routine care (DOT) to the intervention (99DOTS-based treatment supervision) beginning in month 2, with the order determined randomly. 99DOTS enables patients to be monitored while self-administering TB medicines. Patients receive daily automated short message service (SMS) dosing reminders and confirm dosing by calling toll-free numbers. The primary effectiveness outcome is the proportion of patients completing TB treatment. With 18 clusters randomised into six steps and an average cluster size of 15 patients per month, the study will have 89% power to detect a 10% or greater increase in treatment completion between the routine care and intervention periods. Secondary outcomes include more proximal effectiveness measures as well as quantitative and qualitative assessments of the reach, adoption and implementation of the intervention.

ETHICS AND DISSEMINATION

Ethics approval was granted by institutional review boards at Makerere University School of Public Health and the University of California San Francisco. Findings will be disseminated through peer-reviewed publications, presentations at scientific conferences and presentations to key stakeholders.

TRIAL REGISTRATION NUMBER

PACTR201808609844917.

Factors Influencing Patient Adherence to Tuberculosis Treatment in Ethiopia: A Literature Review

Background: Tuberculosis (TB) is a major global public health problem and one of the leading causes of death among infectious diseases. Although TB can be cured with first-line antibiotics treatment of 6 months regimen, non-adherence to the treatment remains the main challenge for TB prevention and control. Interventions to promote adherence need to address multiple underlying factors linked to non-adherence, which requires a synthesis of studies to understand these factors in the local context. Our review accordingly examines these factors for TB treatment in Ethiopia. Methods: Articles were searched from PubMed and ScienceDirect databases, as well as manual searches through Google and Google Scholar search engines. Both quantitative and qualitative studies that showed factors associated with or reasons for non-adherence, default or loss to follow up from TB treatment were included. A total of 276 articles were screened, and 29 articles were ultimately included in the review. Findings: The extracted factors were synthesized thematically into seven dimensions of patient-centred, social, economic, health system, therapy, lifestyle, and geographic access factors. More than 20 distinct factors were identified under these headings. Some of these factors may also apply quite widely in other settings, with greater or lesser influence, but some are particularly applicable to the Ethiopian setting. Conclusion: Helping patients to achieve full adherence to TB medication is a complex problem as it is influenced by interplay between many factors. Healthcare managers, providers, and researchers need to consider and address multiple underlying factors when designing adherence interventions. This work provides a reference set of such factors for Ethiopian interventions.

Electronic pillbox-enabled self-administered therapy versus standard directly observed therapy for tuberculosis medication adherence and treatment outcomes in Ethiopia (SELFTB): protocol for a multicenter randomized controlled trial

BACKGROUND

To address the multifaceted challenges associated with tuberculosis (TB) in-person directly observed therapy (DOT), the World Health Organization recently recommended that countries maximize the use of digital adherence technologies. Sub-Saharan Africa needs to investigate the effectiveness of such technologies in local contexts and proactively contribute to global decisions around patient-centered TB care. This study aims to evaluate the effectiveness of pillbox-enabled self-administered therapy (SAT) compared to standard DOT on adherence to TB medication and treatment outcomes in Ethiopia. It also aims to assess the usability, acceptability, and cost-effectiveness of the intervention from the patient and provider perspectives.

METHODS

This is a multicenter, randomized, controlled, open-label, superiority, effectiveness-implementation hybrid, mixed-methods, two-arm trial. The study is designed to enroll 144 outpatients with new or previously treated, bacteriologically confirmed, drug-sensitive pulmonary TB who are eligible to start the standard 6-month first-line anti-TB regimen. Participants in the intervention arm (n = 72) will receive 15 days of HRZE-isoniazid, rifampicin, pyrazinamide, and ethambutol-fixed-dose combination therapy in the evriMED500 medication event reminder monitor device for self-administration. When returned, providers will count any remaining tablets in the device, download the pill-taking data, and refill based on preset criteria. Participants can consult the provider in cases of illness or adverse events outside of scheduled visits. Providers will handle participants in the control arm (n = 72) according to the standard in-person DOT. Both arms will be followed up throughout the 2-month intensive phase. The primary outcomes will be medication adherence and sputum conversion. Adherence to medication will be calculated as the proportion of patients who missed doses in the intervention (pill count) versus DOT (direct observation) arms, confirmed further by IsoScreen urine isoniazid test and a self-report of adherence on eight-item Morisky Medication Adherence Scale. Sputum conversion is defined as the proportion of patients with smear conversion following the intensive phase in intervention versus DOT arms, confirmed further by pre-post intensive phase BACTEC MGIT TB liquid culture. Pre-post treatment MGIT drug susceptibility testing will determine whether resistance to anti-TB drugs could have impacted culture conversion. Secondary outcomes will include other clinical outcomes (treatment not completed, death, or loss to follow-up), cost-effectiveness-individual and societal costs with quality-adjusted life years-and acceptability and usability of the intervention by patients and providers.

DISCUSSION

This study will be the first in Ethiopia, and of the first three in sub-Saharan Africa, to determine whether electronic pillbox-enabled SAT improves adherence to TB medication and treatment outcomes, all without affecting the inherent dignity and economic wellbeing of patients with TB.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04216420. Registered on 2 January 2020.

Implementation fidelity of hospital based directly observed therapy for tuberculosis treatment in Bhutan: mixed-method study

Background

Direct observed treatment (DOT) has been implemented in Bhutan since 1997 and currently, it is offered in various model of delivery including a combination of hospital based, home based DOT and ambulatory DOT. Overall, treatment success rate for tuberculosis cases is higher than the global target; however, it is still need to be improved. Evaluation to the implementation fidelity of DOT is important to identify potential rooms for improvement. This study aimed to assess two major components of the program’s implementation fidelity: to assess patient’s adherence to DOT and explore factors for adherence; to assess provider’s compliance with DOT guideline and explore factors for compliance.

Methods

This research used a sequential explanatory mixed method. The conceptual framework of implementation fidelity was adopted to guide this study design. The cross-sectional study of TB patients was enrolled in two hospitals with highest TB load, between September to November 2017 in Bhutan. Interviewer assisted survey was conducted with 139 TB patients who visited the hospital in continuation phase. In-depth interview was then conducted with nine TB patients and four health staffs to explore the barriers and enablers of DOT.

Results

Total of 61.9% (86/139) of patients has received DOT at intensive phase. Proportion was higher among MDR-TB cases (100%), and smear sputum positive TB cases (84.7%). In the continuation phase, 5.8% of patients took medicine at hospital, 48.9% at home and the rest 45.3% no longer practiced DOT. More than 90% of patient received correct dosage and standard regimen of anti-TB drugs according to the guideline. The key factors affecting poor adherence to DOT as perceived by patients were; lack of willingness to visit the clinic on daily basis due to long distance, financial implications and family support. However, patient’s satisfaction to the quality of TB treatment service delivery was high (98.6%). Providing incentives to the patient was most agreed enabler felt by both health workers and patients.

Conclusion

In the selected hospital sites, the patient’s adherence to DOT and provider’s compliance with DOT guideline is partially implemented; the coverage and the duration of DOT is very low, therefore, need to revise and improve DOT model and structure.

Combined effect of pill refilling and self-medication reminder system on patients' adherence to tuberculosis treatment during continuation phase in Northwest Ethiopia: a study protocol for randomised controlled trial

Introduction

Patients’ failure to adhere on tuberculosis (TB) treatment leads to drug resistance, relapse and death. Non-adherence to TB treatment is higher during continuation treatment phase. The study aimed to evaluate effectiveness of combined pill refilling and medication reminders on adherence to TB treatment.

Methods and analysis

A two-arm randomised controlled trial on adult patients with TB was used during continuation treatment phase. In the first arm, in addition to usual care, participants will receive cellphone-based daily medication and weekly pill refilling reminders. In the control arm, participants will receive only usual care. The study will use a covariate adaptive randomisation technique to balance covariates during allocation. The primary outcome is patients’ adherence to TB treatment and secondary outcomes are attendance to clinic and treatment outcomes. We apply intention to treat with generalised linear mixed model.

Ethics and dissemination

Ethical approval was obtained from Institutional Review Board of University of Gondar. Written informed consent was applied during enrolment. We will publish findings in peer-reviewed, scientific journals and conferences.

Trial registration number

PACTR201901552202539.

Community Contribution to Tuberculosis Care in the Krachi West District of Ghana: A Qualitative Study

BACKGROUND

Eradicating tuberculosis (TB) is one of the targets of the recently constituted Sustainable Development Goal (SDG) Three. In the light of limitations inherent in prevailing tuberculosis care and the global urgency to improve TB care, decentralising TB care beyond health facilities by harnessing the contribution of communities is essential in ensuring effective tuberculosis care. In this paper, we explored community contribution to TB care in the Krachi West District of Ghana.

METHODS

In this qualitative study, 24 TB stakeholders made up of 7 health workers, 9 tuberculosis patients, 4 community health volunteers, 2 treatment supporters, and 2 opinion leaders were interviewed. Data collected were analysed manually, but thematically. Statements of the participants were presented as quotes to substantiate issues discussed.

RESULTS

Community contribution to TB care was low. Most of the community members were not aware of any community level activity towards tuberculosis care. Though patients were mainly the ones responsible for the selection of their treatment supporters, there were instances where health workers selected supporters for them without their consent. Some treatment supporters were also not given any education concerning their roles in supporting their patients, resulting in some patients defaulting treatment and others taking their medications wrongfully.

CONCLUSION

Our study revealed low community involvement in tuberculosis care in the Krachi West District of Ghana. Community sensitisation on the World Health Organisation's Directly Observed Treatment Strategy (which Ghana adopted in 1994) to increase community involvement in tuberculosis activities is, therefore, recommended.

Evidence based interventions and implementation gaps in control of tuberculosis: A systematic review in low and middle-income countries with special focus on India

We synthesised the findings of intervention studies on Tuberculosis control (TC) in low- and middle-income countries with specific reference to India through a systematic review during the period 2000-2017 in order to identify the implementation gap. The research questions were framed using PICOS (population, intervention, comparison, outcomes and study design) framework and PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were used for study selection. The search was mainly carried out in MEDLINE/PubMed, Web of Knowledge and Cochrane libraries. DOTS was found to be the most effective intervention program for control of Tuberculosis. Lack of utilization of the capacity of various level health staff, accessibility in utilizing health facilities and insufficient community involvement was identified as the major gaps for TC. In the case of India, each state has its own priority and applicability for different TC interventions. Most of the studies on implementation of the TC program supported the encouraging effect of the intervention in the control of Tuberculosis. The specific need of each country is clearly reflected in many of the selected studies. In order to establish the association of intervention and its implementation gaps on TB control, more rigorous evaluation methods are needed including meta-analysis. REGISTRATION: PROSPERO registration number: CRD42018070406.

Patients' experiences and perceptions on associates of TB treatment adherence: a qualitative study on DOTS service in public health centers in Addis Ababa, Ethiopia

Background

Ethiopia is one of the countries with the highest TB burdens in the world. There are multitude of challenges related to the implementation of DOTS and adherence to treatment. This study aimed to assess patients’ experiences and perceptions on associates of TB treatment adherence in Addis Ababa, Ethiopia.

Methods

A phenomenological approach was employed to generate qualitative data through the in-depth interview of TB patients attending DOTS in two public health centers. A total of ten participants, who were purposively selected till conceptual saturation was reached, were interviewed using topic guides prepared in line with the study objectives. Interviews were tape-recorded, transcribed verbatim, and translated to English. Open Code software was used to facilitate analysis. Themes pertaining to patient, health service, therapeutic, and socioeconomic factors were developed, and findings were presented accordingly.

Results

Experience of missing medications was reported by a single participant. Most informants pointed out that TB is transmitted through coughing and expectorate, and prevented by letting in open air in public gatherings. However, most of them stated cold air and few mentioned contaminated food as causes of TB. Perceived risk of non-adherence to medication was among recounted reasons behind treatment adherence. Some informants also recalled to have had the intention of withdrawing medication due to perceived wellness, which they actually did not change into action. Most of the participants generally had smooth relationships with their DOTS service providers. Even if more than half of the patients preferred follow-ups by the same professional, most received DOTS service by two or more service providers.

Conclusions

TB treatment non-adherence was not found to be a major challenge among the study participants. Perceived risk and wellness were implied to be responsible factors for adherence. Albeit the fact that few informants encountered unethical behaviors by some health professionals, interviewed patients generally had positive evaluation of the patient-provider relationship and the DOTS service obtained. There is a need to train and monitor DOTS service providers and ensure the provision of DOTS service by the same provider throughout the treatment period of a given patient.

Community-based directly observed treatment for TB patients to improve HIV services: a cross-sectional study in a South African province

Background

There is uncertainty about how directly observed treatment (DOT) support for tuberculosis (TB) can be delivered most effectively and how DOT support can simultaneously be used to strengthen human immunodeficiency virus (HIV) prevention and control among TB patients. This study describes how DOT support by community health workers (CHWs) was used in four municipalities in the Free State province – a high TB/HIV burden, poorly-resourced setting – to provide HIV outreach, referrals, and health education for TB patients.

Methods

The study was part of a larger cross-sectional study of HIV counselling and testing (HCT) among 1101 randomly-selected TB patients registered at 40 primary health care (PHC) facilities (clinics and community health centres) across small town/rural and large town/urban settings. Univariate analysis of percentages, chi-square tests and t-tests for difference in means were used to describe differences between the types of TB treatment support and patient characteristics, as well as the types of – and patient satisfaction with – HIV information and referrals received from various types of treatment supporters including home-based DOT supporters, clinic-based DOT supporters or support from family/friends/employers. Multivariate logistic regression was used to predict the likelihood of not having receiving home-based DOT and of never having received HIV counselling. The independent variables include poverty-related health and socio-economic risk factors for poor outcomes. Statistical significance is shown using a 95% confidence interval and a 0.05 p-value.

Results

Despite the fact that DOT support for all TB patients was the goal of South African health policy at the time (2012), most TB patients were not receiving formal DOT support. Only 155 (14.1%) were receiving home-based DOT, while 114 (10.4%) received clinic-based DOT. TB patients receiving home-based DOT reported higher rates of HIV counselling than other patients.

Conclusions

Public health providers should train DOT supporters to provide HIV prevention and target DOT to those at greatest risk of HIV, particularly those at greatest socio-economic risk.

'Before reaching the last mile'- Knowledge, attitude, practice and perceived barriers related to tuberculosis directly observed therapy among ASHA workers in Central India: A mixed method study

Introduction: Community-based direct observed treatment (DOT) providers are an important bridge for the national tuberculosis programme in India to reach the unreached. The present study has explored the knowledge, attitude, practice and barriers perceived by the community-based DOT providers.

Methods: Mixed–methods study design was used among 41 community-based DOT providers (Accredited Social Health Activist (ASHAs)) working in 67 villages from a primary health center in Raisen district of Madhya Pradesh, India. The cross-sectional quantitative component assessed the knowledge and practices and three focus-group discussions explored the attitude and perceived barriers related to DOT provision.

Result: ‘Adequate knowledge’ and ‘satisfactory practice’ related to DOT provision was seen in 14 (34%) and 13 (32%) ASHAs respectively. Only two (5%) received any amount of honorarium for completion of DOT in last 3 years. The focus-group discussions revealed unfavourable attitude; inadequate training and supervision, non-payment of honorarium, issues related to assured services after referral and patient related factors as the barriers to satisfactory practice of DOT.

Conclusion: Study revealed inadequate knowledge and unsatisfactory practice related to DOT provision among ASHAs. Innovations addressing the perceived barriers to improve practice of DOT provision by ASHAs are urgently required.

Tuberculosis care strategies and their economic consequences for patients: the missing link to end tuberculosis

BACKGROUND

While investment in the development of Tuberculosis (TB) treatment strategies is essential, it cannot be assumed that the strategies are affordable for TB patients living in countries with high economic constraints. This study aimed to determine the economic consequences of directly observed therapy for TB patients.

METHODS

A cross-sectional cost-of-illness analysis was conducted between September to November 2015 among 576 randomly selected adult TB patients who were on directly observed treatment in 27 public health facilities in Addis Ababa, Ethiopia. Data were collected using interviewer-administered questionnaire adapted from the Tool to Estimate Patients' Costs. Mean and median costs, reduction of productivity, and household expenditure of TB patients were calculated and ways of coping costs captured. Eta (η), Odds ratio and p values were used to measure association between variables.

RESULTS

Of the total 576 TB patients enrolled, 43 % were smear-positive pulmonary TB (PTB), 17 % smear-negative PTB, 37 % Extra-PTB and 3 % multi-drug resistant TB cases. Direct (Out-of-Pocket) mean and median costs of TB illness to patients were $123.0 (SD = 58.8) and $125.78 (R = 338.12), respectively, and indirect (loss income) mean and median costs were $54.26 (SD = 43.5) and $44.61 (R = 215.6), respectively. Mean and median total cost of TB illness to patient were $177.3 (SD = 78.7) and $177.1 (R = 461.8), respectively. The total cost had significant association with patient's household income, residence, need for additional food, and primary income (P <0.05). Direct costs were catastrophic for 63 % of TB patients, regardless of significant difference between gender (P = 0.92) and type of TB cases (P = 0.37). TB patients mean productivity and income reduced by 37 and 10 %, respectively, compared with pre-treatment level, while mean household expenditure increased by 33 % and working hours reduced by 78 % due to TB illness. Income quartile categories were directly correlated with catastrophic costs (η = 0.684).

CONCLUSION

Despite the availability of free-of-charge anti-TB drugs, TB patients were suffering from out-of-pocket payments with catastrophic consequences, which in turn were hampering the efforts to end TB. TB patients in resource-limited countries deserve integrated patient-centered care with comprehensive health insurance coverage, financial incentives, and nutrition support to reduce catastrophic costs and retain them in care. Such countries should induce home-based directly observed therapy programs to reduce costs due to attending health facilities, intensify home treatment of critically-ill patients with impaired mobility, and reduce the spread of TB due to patients traveling to seek care.