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Zary M, Mohamed MS, Kafie C, Chilala CI, Bahukudumbi S, Foster N, Gore G, Fielding KL, Subbaraman R, Schwartzman K. The performance of digital technologies for measuring tuberculosis medication adherence: a systematic review. BMJ Glob Health 2024; 9:e015633. [PMID: 39013639 PMCID: PMC11288144 DOI: 10.1136/bmjgh-2024-015633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/21/2024] [Indexed: 07/18/2024] Open
Abstract
INTRODUCTION Digital adherence technologies (DATs), such as phone-based technologies and digital pillboxes, can provide more person-centric approaches to support tuberculosis (TB) treatment. However, there are varying estimates of their performance for measuring medication adherence. METHODS We conducted a systematic review (PROSPERO-CRD42022313526), which identified relevant published literature and preprints from January 2000 to April 2023 in five databases. Studies reporting quantitative data on the performance of DATs for measuring TB medication adherence against a reference standard, with at least 20 participants, were included. Study characteristics and performance outcomes (eg, sensitivity, specificity and predictive values) were extracted. Sensitivity was the proportion correctly classified as adherent by the DAT, among persons deemed adherent by a reference standard. Specificity was the proportion correctly classified as non-adherent by the DAT, among those deemed non-adherent by a reference standard. RESULTS Of 5692 studies identified by our systematic search, 13 met inclusion criteria. These studies investigated medication sleeves with phone calls (branded as '99DOTS'; N=4), digital pillboxes N=5), ingestible sensors (N=2), artificial intelligence-based video-observed therapy (N=1) and multifunctional mobile applications (N=1). All but one involved persons with TB disease. For medication sleeves with phone calls, compared with urine testing, reported sensitivity and specificity were 70%-94% and 0%-61%, respectively. For digital pillboxes, compared with pill counts, reported sensitivity and specificity were 25%-99% and 69%-100%, respectively. For ingestible sensors, the sensitivity of dose detection was ≥95% compared with direct observation. Participant selection was the most frequent potential source of bias. CONCLUSION The limited number of studies available suggests suboptimal and variable performance of DATs for dose monitoring, with significant evidence gaps, notably in real-world programmatic settings. Future research should aim to improve understanding of the relationships of specific technologies, settings and user engagement with DAT performance and should measure and report performance in a more standardised manner.
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Affiliation(s)
- Miranda Zary
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mona Salaheldin Mohamed
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Cedric Kafie
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Shruti Bahukudumbi
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Nicola Foster
- TB Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Genevieve Gore
- McGill Schulich Library of Physical Sciences, Life Sciences and Engineering, McGill University, Montreal, Quebec, Canada
| | | | - Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Kevin Schwartzman
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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Mtenga AE, Maro RA, Dillip A, Msoka P, Emmanuel N, Ngowi K, Sumari-de Boer M. Acceptability of a Digital Adherence Tool Among Patients With Tuberculosis and Tuberculosis Care Providers in Kilimanjaro Region, Tanzania: Mixed Methods Study. Online J Public Health Inform 2024; 16:e51662. [PMID: 38922643 PMCID: PMC11237791 DOI: 10.2196/51662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 02/27/2024] [Accepted: 05/09/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND The World Health Organization has recommended digital adherence tools (DATs) as a promising intervention to improve antituberculosis drug adherence. However, the acceptability of DATs in resource-limited settings is not adequately studied. OBJECTIVE We investigated the acceptability of a DAT among patients with tuberculosis (TB) and TB care providers in Kilimanjaro, Tanzania. METHODS We conducted a convergent parallel mixed methods study among patients with TB and TB care providers participating in our 2-arm cluster randomized trial (REMIND-TB). The trial aimed to investigate whether the evriMED pillbox with reminder cues and adherence feedback effectively improves adherence to anti-TB treatment among patients with TB in Kilimanjaro, Tanzania. We conducted exit and in-depth interviews among patients as well as in-depth interviews among TB care providers in the intervention arm. We conducted a descriptive analysis of the quantitative data from exit interviews. Translated transcripts and memos were organized using NVivo software. We employed inductive and deductive thematic framework analysis, guided by Sekhon's theoretical framework of acceptability. RESULTS Out of the 245 patients who completed treatment, 100 (40.8%) were interviewed during exit interviews, and 18 patients and 15 TB care providers were interviewed in-depth. Our findings showed that the DAT was highly accepted: 83% (83/100) expressed satisfaction, 98% (98/100) reported positive experiences with DAT use, 78% (78/100) understood how the intervention works, and 92% (92/100) successfully used the pillbox. Good perceived effectiveness was reported by 84% (84/100) of the participants who noticed improved adherence, and many preferred continuing receiving reminders through SMS text messages, indicating high levels of self-efficacy. Ethical concerns were minimal, as 85 (85%) participants did not worry about remote monitoring. However, some participants felt burdened using DATs; 9 (9%) faced difficulties keeping the device at home, 12 (12%) were not pleased with receiving daily reminder SMS text messages, and 30 (30%) reported challenges related to mobile network connectivity issues. TB care providers accepted the intervention due to its perceived impact on treatment outcomes and behavior change in adherence counseling, and they demonstrated high level of intervention coherence. CONCLUSIONS DATs are highly acceptable in Tanzania. However, some barriers such as TB-related stigma and mobile network connectivity issues may limit acceptance. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1186/s13063-019-3483-4.
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Affiliation(s)
- Alan Elias Mtenga
- mHealth Department, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
- Department of Life Science and Bioengineering, Nelson Mandela African Institution of Science and Technology, Arusha, United Republic of Tanzania
| | - Rehema Anenmose Maro
- mHealth Department, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
| | - Angel Dillip
- Department of Life Science and Bioengineering, Nelson Mandela African Institution of Science and Technology, Arusha, United Republic of Tanzania
- Department of Health system, Apotheker Health Access Initiatives, Tanzania, Dar es salaam, United Republic of Tanzania
| | - Perry Msoka
- mHealth Department, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
| | - Naomi Emmanuel
- mHealth Department, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
| | - Kennedy Ngowi
- mHealth Department, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
| | - Marion Sumari-de Boer
- mHealth Department, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
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Naidoo K, Perumal R, Cox H, Mathema B, Loveday M, Ismail N, Omar SV, Georghiou SB, Daftary A, O'Donnell M, Ndjeka N. The epidemiology, transmission, diagnosis, and management of drug-resistant tuberculosis-lessons from the South African experience. THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00144-0. [PMID: 38527475 DOI: 10.1016/s1473-3099(24)00144-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/29/2024] [Accepted: 02/20/2024] [Indexed: 03/27/2024]
Abstract
Drug-resistant tuberculosis (DR-TB) threatens to derail tuberculosis control efforts, particularly in Africa where the disease remains out of control. The dogma that DR-TB epidemics are fueled by unchecked rates of acquired resistance in inadequately treated or non-adherent individuals is no longer valid in most high DR-TB burden settings, where community transmission is now widespread. A large burden of DR-TB in Africa remains undiagnosed due to inadequate access to diagnostic tools that simultaneously detect tuberculosis and screen for resistance. Furthermore, acquisition of drug resistance to new and repurposed drugs, for which diagnostic solutions are not yet available, presents a major challenge for the implementation of novel, all-oral, shortened (6-9 months) treatment. Structural challenges including poverty, stigma, and social distress disrupt engagement in care, promote poor treatment outcomes, and reduce the quality of life for people with DR-TB. We reflect on the lessons learnt from the South African experience in implementing state-of-the-art advances in diagnostic solutions, deploying recent innovations in pharmacotherapeutic approaches for rapid cure, understanding local transmission dynamics and implementing interventions to curtail DR-TB transmission, and in mitigating the catastrophic socioeconomic costs of DR-TB. We also highlight globally relevant and locally responsive research priorities for achieving DR-TB control in South Africa.
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Affiliation(s)
- Kogieleum Naidoo
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Rubeshan Perumal
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Helen Cox
- Institute of Infectious Diseases and Molecular Medicine, Wellcome Centre for Infectious Disease Research and Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Barun Mathema
- Mailman School of Public Health, Columbia University, New York City, NY, USA
| | - Marian Loveday
- South African Medical Research Council, Durban, South Africa
| | - Nazir Ismail
- School of Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Shaheed Vally Omar
- Centre for Tuberculosis, National & WHO Supranational TB Reference Laboratory, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa
| | | | - Amrita Daftary
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; School of Global Health and Dahdaleh Institute of Global Health Research, York University, Toronto, ON, Canada
| | - Max O'Donnell
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY, USA; Department of Epidemiology, Columbia University Irving Medical Center, New York City, NY, USA
| | - Norbert Ndjeka
- TB Control and Management, Republic of South Africa National Department of Health, Pretoria, South Africa
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Ogello VA, Rono BK, Ngure K, Sedah E, Thuo NB, Musinguzi N, Baeten JM, Bukusi EA, Mugo NR, Haberer JE. Acceptability and feasibility of long-term, real-time electronic adherence monitoring of HIV pre-exposure prophylaxis (PrEP) use among young women in Kenya: A mixed methods study. PLoS One 2024; 19:e0299168. [PMID: 38451884 PMCID: PMC10919630 DOI: 10.1371/journal.pone.0299168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
Real-time electronic adherence monitoring involves "smart" pill boxes that record and monitor openings as a proxy for pill taking and may be useful in understanding and supporting PrEP use; however, acceptability and/or feasibility for PrEP users is uncertain. We sought to understand the experiences of using a real-time electronic adherence monitor for PrEP delivery among young women in Kisumu and Thika, Kenya. We used the Wisepill device to monitor PrEP use among 18-24-year-old women for two years. Half of the participants were randomized to also receive SMS adherence reminders (daily or as needed for missed doses). We assessed acceptability quantitatively and qualitatively according to the four constructs of Unified Theory of Acceptance and Use of Technology (UTAUT): performance expectancy, effort expectancy, social influence, and facilitating conditions. We assessed feasibility by monitor functionality during periods of PrEP use. We analyzed quantitative data descriptively and compared by site and over time; qualitative data were analyzed inductively and deductively. The median age was 21 years (IQR 19-22), median education was 12 years (IQR 10-13), 182 (53%) had disclosed PrEP use, and 55 (16%) reported recent intimate partner violence. Most participants reported high levels of usefulness and high interest in using the monitor with few problems or worries reported throughout follow-up. Feasibility was high overall with some differences by site (96% functional monitor days in Kisumu vs 88% in Thika). Few monitors were reported lost (N = 29; 8%) or dysfunctional (N = 11; 3%). In qualitative interviews, electronic monitoring was perceived as useful because it supported privacy, confidentiality, easy storage, and PrEP adherence. Effort was generally considered low. Participants expressed some concern for stigma from monitor and/or PrEP use. Facilitating conditions involved the monitor size, color, and battery life. Overall, real-time electronic adherence monitoring was a highly acceptable and feasible approach to understand PrEP adherence among young women in a sub-Saharan African setting.
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Affiliation(s)
- Vallery A. Ogello
- Center of Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Eric Sedah
- Center for microbiology research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Nicholas B. Thuo
- Center of Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Gilead Sciences, Foster City, California, United States of America
| | - Elizabeth A. Bukusi
- Center for microbiology research, Kenya Medical Research Institute, Kisumu, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Nelly R. Mugo
- Center of Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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Reis K, Wolf A, Perumal R, Seepamore B, Guzman K, Ross J, Cheung K, Amico KR, Brust JC, Padayatchi N, Friedland G, Naidoo K, Daftary A, Zelnick J, O’Donnell M. Differentiated service delivery framework for people with multidrug-resistant tuberculosis and HIV co-infection. J Acquir Immune Defic Syndr 2024; 96:00126334-990000000-00374. [PMID: 38323838 PMCID: PMC11300702 DOI: 10.1097/qai.0000000000003394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
INTRODUCTION For people living with HIV/AIDS, care is commonly delivered through Differentiated Service Delivery (DSD). Although people with multidrug-resistant tuberculosis (MDR-TB) and HIV/AIDS experience severe treatment associated challenges, there is no DSD model to support their treatment. In this study, we defined patterns of medication adherence and characterized longitudinal barriers to inform development of an MDR-TB/HIV DSD framework. METHODS Adults with MDR-TB and HIV initiating bedaquiline (BDQ) and receiving antiretroviral therapy (ART) in KwaZulu-Natal, South Africa, were enrolled and followed through the end of MDR-TB treatment. Electronic dose monitoring devices (EDM) measured BDQ and ART adherence. Longitudinal focus groups were conducted and transcripts analyzed thematically to describe discrete treatment stage-specific and cross-cutting treatment challenges. RESULTS 283 participants were enrolled and followed through treatment completion (median 17.8 months [IQR 16.5-20.2]). Thirteen focus groups were conducted. Most participants (82.7%, 234/283) maintained high adherence (mean BDQ adherence 95.3%; mean ART adherence 85.5%), but an adherence-challenged subpopulation with <85% cumulative adherence (17.3%, 49/283) had significant declines in mean weekly BDQ adherence from 94.9% to 39.9% (p<0.0001) and mean weekly ART adherence from 83.9% to 26.6% (p<0.0001) over 6 months. Psychosocial, behavioral, and structural obstacles identified in qualitative data were associated with adherence deficits in discrete treatment stages, and identified potential stage specific interventions. CONCLUSION A DSD framework for MDR-TB/HIV should intensify support for adherence-challenged subpopulations, provide multi-modal support for adherence across the treatment course and account for psychosocial, behavioral, and structural challenges linked to discrete treatment stages.
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Affiliation(s)
- Karl Reis
- Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY
| | - Allison Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY
| | - Rubeshan Perumal
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Boitumelo Seepamore
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Kevin Guzman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY
| | - Jesse Ross
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY
| | - Ken Cheung
- Department of Biostatistics, Columbia University Irving Medical Center, New York City, NY
| | - K. Rivet Amico
- University of Michigan School of Public Health, Ann Arbor, MI
| | - James C.M. Brust
- Divisions of General Internal Medicine and Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Nesri Padayatchi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Gerald Friedland
- Department of Medicine (Infections Diseases), Yale University School of Medicine, New Haven, CT
| | - Kogieleum Naidoo
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Amrita Daftary
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, Canada
| | - Jennifer Zelnick
- Graduate School of Social Work, Touro University, New York City, NY
| | - Max O’Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- Department of Epidemiology, Columbia University Irving Medical Center, New York City, NY
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Li W, Su M, Zhang W, Fan X, Li R, Gao Y, Wei X. Barriers and facilitators of implementing electronic monitors to improve adherence and health outcomes in tuberculosis patients: protocol for a systematic review based on the Consolidated Framework for Implementation Research. Health Res Policy Syst 2023; 21:115. [PMID: 37915089 PMCID: PMC10621129 DOI: 10.1186/s12961-023-01054-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 09/25/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) has been regarded as 'a relentless scourge', increasing morbidity and mortality and burdening vulnerable populations. Poor adherence to TB treatment and ineffective traditional interventions hinders TB control. A novel TB approach called 'electronic monitors', equipping medication boxes with daily audio or visual reminders for electronically monitoring medication intake, seems promising in improving adherence and health outcomes and overcoming the weaknesses of traditional interventions. However, no review has systematically examined and synthesized the influencing factors of implementing electronic monitors. Implementation research offers the means to analyse the influencing factors of the implementation and its process, fitting well with the aim of this review. Therefore, the widely recognized Consolidated Framework for Implementation Research (CFIR), which offers a common taxonomy for evaluating intervention implementation, will be adopted to systematically identify barriers and facilitators of the electronic monitors for improving adherence and health outcomes in patients with TB. METHODS AND ANALYSIS The systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Literature research will be conducted in five electronic databases (Ovid MEDLINE, CINAHL, EMBASE, Cochrane Library and Web of Science) to identify the barriers and facilitators of implementing electronic monitors in patients with TB. The CFIR will be used as a guide for categorizing and synthesizing the barriers and facilitators. Study screening, data extraction, quality appraisal and data analysis will be conducted by two independent reviewers. The use of additional reviewers will solve any disagreements between the two reviewers. DISCUSSION Given the increased prominence of TB epidemiology and the adherence problem of electronic monitors, there is a solid rationale for synthesizing the existing studies via the CFIR. The findings and conclusion of this review will lay bare the achievements and effectiveness of implementing electronic monitors, as well as the attendant gaps and limitations. Further strategies for facilitating the implementation of electronic monitors will also be explored. This review will be of essential significance for research and practice, supporting future academic research initiatives centred on patients with TB and aiding electronic monitor design in lowering the morbidity and mortality associated with TB disease. TRIAL REGISTRATION NUMBER PROSPERO: CRD42023395747.
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Affiliation(s)
- Wenhui Li
- School of Public Administration, Inner Mongolia University, Hohhot, China
| | - Min Su
- School of Public Administration, Inner Mongolia University, Hohhot, China.
| | - Weile Zhang
- School of Public Administration, Inner Mongolia University, Hohhot, China
| | - Xiaojing Fan
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China
| | - Renzhong Li
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yulong Gao
- Inner Mongolia Center for Disease Control and Prevention, Hohhot, China
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Mukora R, Ahumah B, Maraba N, Orrell C, Jennings L, Naidoo P, Fielding KL, Velen K, Charalambous S, Chetty-Makkan CM. Acceptability of using the medication monitor and experience of a differentiated care approach for TB treatment adherence among people living with TB in South Africa. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001885. [PMID: 37889875 PMCID: PMC10610070 DOI: 10.1371/journal.pgph.0001885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The introduction of digital adherence technologies (DATs) such as medication monitors in tuberculosis (TB) programmes supports treatment adherence among people with tuberculosis (PWTB). We evaluated the acceptability of using medication monitors (Wisepill evriMED) prompting a stepwise differentiated care approach (DCA), involving short message service (SMS), phone calls, home visits and motivational counselling, among PWTB in South Africa. METHODS We conducted 62 in-depth interviews with participants in local languages across three provinces (January-October 2020), purposively selected by treatment month, adherence history and gender. Interviews were audio recorded, transcribed verbatim and translated. Using a deductive approach and the Theoretical Framework for Acceptability (TFA), we explored acceptability across the sample attributes. RESULTS PWTB across adherence histories showed a positive attitude to using the evriMED device and receiving the DCA support. PWTB described the SMS reminders and phone calls as effective reminders, though home visits were less acceptable, due to perceived stigma. Despite willingness to participate in the intervention, the large size of the monitor and sound of the alarm drew attention, potentially causing embarrassment and stigma. Due to perceived stigma, some PWTB adapted the intervention by leaving the monitor at home after removing the pills to ensure that someone else tracked usage, while the PWTB used alternative reminders such as cell phones to take their medication. CONCLUSION Although PWTB showed a positive attitude towards the intervention, perceived stigma contributed to participants adapting their lifestyle to meet treatment adherence requirements without using the monitor. However, the medication monitor was a tool that seemed to prompt this personal change in behaviour. Achieving people-centered TB care, including the introduction of DATs, will require that TB programmes incorporate PWTB insights to maximize their use and effectiveness.
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Affiliation(s)
- Rachel Mukora
- The Aurum Institute, Aurum House, Parktown, Johannesburg, South Africa
- University of Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Barack Ahumah
- University of Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Noriah Maraba
- The Aurum Institute, Aurum House, Parktown, Johannesburg, South Africa
| | - Catherine Orrell
- Department of Medicine, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Desmond Tutu Health Foundation, Cape Town, South Africa
| | | | - Pren Naidoo
- Stellenbosch University, Stellenbosch, South Africa
| | - Katherine L. Fielding
- University of Witwatersrand, School of Public Health, Johannesburg, South Africa
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kavindhran Velen
- The Aurum Institute, Aurum House, Parktown, Johannesburg, South Africa
| | - Salome Charalambous
- The Aurum Institute, Aurum House, Parktown, Johannesburg, South Africa
- University of Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Candice M. Chetty-Makkan
- Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
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Dreyer AJ, Nightingale S, Andersen LS, Lee JS, Gouse H, Safren SA, O’Cleirigh C, Thomas KGF, Joska J. Cognitive Performance, as well as Depression, Alcohol Use, and Gender, predict Anti-Retroviral Therapy Adherence in a South African Cohort of People with HIV and Comorbid Major Depressive Disorder. AIDS Behav 2023; 27:2681-2694. [PMID: 36708417 PMCID: PMC10338393 DOI: 10.1007/s10461-023-03992-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 01/29/2023]
Abstract
Depression and cognitive impairment, which commonly coexist in people with HIV (PWH), have been identified as potential barriers to optimal antiretroviral therapy (ART) adherence. We investigated associations between cognitive performance, depression (as well as other sociodemographic, psychosocial and psychiatric variables) and ART adherence in a South African cohort of PWH with comorbid major depressive disorder (MDD). Cognitive performance and ART adherence were assessed at two time points 8 months apart (Nbaseline = 105, Nfollow-up = 81). Adherence was indicated by self-report, objective measures (Wisepill usage and plasma tenofovir-diphosphate levels), and HIV viral suppression. Mixed-effects regression models examined associations across both time points. Univariate models detected no significant associations between cognitive performance (globally and within-domain) and ART adherence. Multivariate modelling showed increased depression severity (β = - 0.54, p < 0.001) and problematic alcohol use (β = 0.73, p = 0.015) were associated with worse adherence as measured subjectively. Being female (OR 0.27, p = 0.048) and having better global cognitive performance (OR 1.83, p = 0.043) were associated with better adherence as indicated by viral suppression. This study identifies poor global cognitive performance, as well as depression and problematic alcohol use, as potential barriers to optimal ART adherence in PWH and comorbid MDD. Hence, clinicians could consider assessing for cognitive deficits, depression, and problematic alcohol use, and should endeavour to provide the appropriate support so as to improve adherence.
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Affiliation(s)
- Anna J. Dreyer
- HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Sam Nightingale
- HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Lena S. Andersen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jasper S. Lee
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA USA
- Department of Psychiatry, Harvard Medical School, Boston, USA
| | - Hetta Gouse
- HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | | | - Conall O’Cleirigh
- Department of Psychology, Harvard Medical School, Boston, MA USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA USA
| | - Kevin G. F. Thomas
- Applied Cognitive Science and Experimental Neuropsychology Team (ACSENT), Department of Psychology, University of Cape Town, Cape Town, South Africa
| | - John Joska
- HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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Kurbaniyazova G, Msibi F, Bogati H, Kal M, Sofa A, Abdi Djama E, Mozi P, Hossain F, Blasco P, Sannino L. TB treatment using family members, treatment supporters and self-administered therapies in rural Papua New Guinea. Public Health Action 2023; 13:60-64. [PMID: 37359064 PMCID: PMC10290259 DOI: 10.5588/pha.22.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/13/2023] [Indexed: 06/28/2023] Open
Abstract
SETTING Papua New Guinea (PNG) has one of the world's highest TB incidence rates. It is difficult for patients to access TB care in remote provinces due to insufficient infrastructure and challenging terrain, making varied, targeted delivery models for treating TB necessary. OBJECTIVE To assess treatment outcomes using self-administered treatment (SAT), family-supported treatment and community-based directly observed therapy (DOT) via treatment supporter (TS) in the PNG context. DESIGN A retrospective, descriptive analysis of routinely collected data from 360 patients at two sites in 2019-2020. All patients were assigned a treatment model based on risk factors (adherence or default) and offered patient education and counselling (PEC), family counselling and transportation fees. End-of-treatment outcomes were assessed for each model. RESULTS Treatment success rates among drug-susceptible TB (DS-TB) were good overall: 91.1% for SAT, 81.4% for family-supported treatment and 77% for DOT patients. SAT was strongly associated with favourable outcomes (OR 5.7, 95% CI 1.7-19.3), as were PEC sessions (OR 4.3, 95% CI 2.5-7.2). CONCLUSION By considering risk factors when determining their treatment delivery model, strong outcomes were seen in all three groups. Multiple modes of treatment administration, tailored to individuals' needs and risk factors, is a feasible, effective, patient-centred care model for hard-to-reach, resource-limited settings.
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Affiliation(s)
| | - F Msibi
- Médecins San Frontières (MSF), Paris, France
| | - H Bogati
- Médecins San Frontières (MSF), Paris, France
| | - M Kal
- National Tuberculosis Programme, Papua New Guinea
| | - A Sofa
- Médecins San Frontières (MSF), Paris, France
| | | | - P Mozi
- Médecins San Frontières (MSF), Paris, France
| | - F Hossain
- Médecins San Frontières (MSF), Paris, France
| | - P Blasco
- Médecins San Frontières (MSF), Paris, France
| | - L Sannino
- Médecins San Frontières (MSF), Paris, France
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10
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Mukora R, Maraba N, Orrell C, Jennings L, Naidoo P, Mbatha MT, Velen K, Fielding K, Charalambous S, Chetty-Makkan CM. Qualitative study exploring the feasibility of using medication monitors and a differentiated care approach to support adherence among people receiving TB treatment in South Africa. BMJ Open 2023; 13:e065202. [PMID: 36868589 PMCID: PMC9990642 DOI: 10.1136/bmjopen-2022-065202] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 02/21/2023] [Indexed: 03/05/2023] Open
Abstract
OBJECTIVES The tuberculosis (TB) MATE study evaluated whether a differentiated care approach (DCA) based on tablet-taking data from Wisepill evriMED digital adherence technology could improve TB treatment adherence. The DCA entailed a stepwise increase in adherence support starting from short message service (SMS) to phone calls, followed by home visits and motivational counselling. We explored feasibility of this approach with providers in implementing clinics. DESIGN Between June 2020 and February 2021, in-depth interviews were conducted in the provider's preferred language, audiorecorded, transcribed verbatim and translated. The interview guide included three categories: feasibility, system-level challenges and sustainability of the intervention. We assessed saturation and used thematic analysis. SETTING Primary healthcare clinics in three provinces of South Africa. PARTICIPANTS We conducted 25 interviews with 18 staff and 7 stakeholders. RESULTS Three major themes emerged: First, providers were supportive of the intervention being integrated into the TB programme and were eager to be trained on the device as it helped to monitor treatment adherence. Second, there were challenges in the adoption system such as shortage of human resources which could serve as a barrier to information provision once the intervention is scaled up. Healthcare workers reported that some patients received incorrect SMS's due to delays in the system that contributed to distrust. Third, DCA was considered as a key aspect of the intervention by some staff and stakeholders since it allowed for support based on individual needs. CONCLUSIONS It was feasible to monitor TB treatment adherence using the evriMED device and DCA. To ensure successful scale-up of the adherence support system, emphasis will need to be placed on ensuring that the device and the network operate optimally and continued support on adhering to treatment which will enable people with TB to take ownership of their treatment journey and help overcome TB-related stigma. TRIAL REGISTRATION NUMBER Pan African Trial Registry PACTR201902681157721.
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Affiliation(s)
- Rachel Mukora
- The Aurum Institute, Implementation Research Division, Johannesburg, South Africa
- University of Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Noriah Maraba
- The Aurum Institute, Implementation Research Division, Johannesburg, South Africa
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, Institute of Infectious Disease and Molecular Medicine and the Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lauren Jennings
- Desmond Tutu HIV Foundation, Institute of Infectious Disease and Molecular Medicine and the Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Pren Naidoo
- University of Stellenbosch, Stellenbosch, South Africa
| | - M Thulani Mbatha
- Interactive Research and Development, Johannesburg, South Africa
| | - Kavindhran Velen
- The Aurum Institute, Implementation Research Division, Johannesburg, South Africa
| | | | - Salome Charalambous
- The Aurum Institute, Implementation Research Division, Johannesburg, South Africa
- University of Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Candice Maylene Chetty-Makkan
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Medina-Marino A, Bezuidenhout D, Ngcelwane N, Cornell M, Wainberg M, Beyrer C, Bekker LG, Daniels J. Qualitative Identification of Intervention Preferences to Support Men's Engagement and Retention in TB Care in South Africa. Am J Mens Health 2022; 16:15579883221129349. [PMID: 36218175 PMCID: PMC9558889 DOI: 10.1177/15579883221129349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Globally and in South African specifically, men account for 56% and 62% of all tuberculosis (TB) cases, respectively. Men are at increased risk of not accessing TB testing or treatment, and having poor treatment outcomes. Unfortunately, no interventions exist to address these issues. Toward the development of targeted, patient-centered TB care and support interventions, we used semistructured interviews to explored men's social network composition, TB testing behaviors, disclosure and treatment support, clinical experiences, and TB's influence on daily living. Data were analyzed using a thematic approach guided by the Network Individual Resource Model to identify mental and tangible resources influential and preferred during engagement in TB treatment. Men emphasized the desire for peer-to-peer support to navigate TB-related stigma and unhealthy masculinity norms. Men advocated for awareness events to educate communities about their challenges with TB. Men strongly suggested that interventions be delivered in familiar locations where men congregate. Since 2022, no TB treatment support interventions have included the preferred components or delivery modes described by men in our study. To improve men's TB-related health outcomes, the global TB community must identify and address men's unique challenges when designing interventions.
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Affiliation(s)
- Andrew Medina-Marino
- Division of Men’s Health, Desmond Tutu
HIV Centre, University of Cape Town, Cape Town, South Africa,Perelman School of Medicine, University
of Pennsylvania, Philadelphia, PA, USA,Research Unit, Foundation for
Professional Development, East London, South Africa,Andrew Medina-Marino, Division of Men’s
Health, Desmond Tutu HIV Centre, University of Cape Town, Cape Town, 7915, South
Africa.
| | - Dana Bezuidenhout
- Research Unit, Foundation for
Professional Development, East London, South Africa,Department of Epidemiology, Mailman
School of Public Health, Columbia University, New York City, NY, USA
| | - Nondumiso Ngcelwane
- Buffalo City Health District, Eastern
Cape Provincial Department of Health, Bisho, South Africa
| | - Morna Cornell
- School of Public Health & Family
Medicine, University of Cape Town, Cape Town, South Africa
| | - Milton Wainberg
- Department of Psychiatry, Columbia
University Vagelos College of Physicians and Surgeons, New York City, NY, USA,New York State Psychiatric Institute,
New York City, NY, USA
| | - Chris Beyrer
- Duke Global Health Institute, Duke
University, Durham, NC, USA,Desmond Tutu HIV Centre, University
of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University
of Cape Town, Cape Town, South Africa
| | - Joseph Daniels
- Edson College of Nursing and Health
Innovation, Arizona State University, Phoenix, AZ, USA
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12
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O’Donnell MR, Padayatchi N, Wolf A, Zelnick J, Daftary A, Orrell C, Nimmo C, Baldwin M, Boodhram R, Maharaj B, Amico KR, Friedland G. Bedaquiline Adherence Measured by Electronic Dose Monitoring Predicts Clinical Outcomes in the Treatment of Patients With Multidrug-Resistant Tuberculosis and HIV/AIDS. J Acquir Immune Defic Syndr 2022; 90:325-332. [PMID: 35195572 PMCID: PMC11077859 DOI: 10.1097/qai.0000000000002940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Novel regimens have revolutionized multidrug-resistant tuberculosis (MDR-TB) treatment; however, medication adherence remains challenging and poorly characterized. We hypothesized that bedaquiline adherence, measured using electronic dose monitoring, would predict MDR-TB treatment outcomes. SETTING This is a prospective cohort study conducted in KwaZulu-Natal, South Africa. METHODS Adults with MDR-TB and HIV initiating bedaquiline and on antiretroviral therapy (ART) were eligible. Separate electronic dose monitoring devices measured bedaquiline and ART adherence through 6 months, calculated as observed versus expected doses. Whole-genome sequencing was performed to identify bedaquiline resistance-associated variants. RESULTS From November 2016 through February 2018, 199 participants with MDR-TB and HIV were enrolled and followed up through treatment completion (median 17.2 months interquartile range 12.2-19.6). The median bedaquiline adherence was higher than ART adherence (97 vs. 89%, P < 0.001) but correlated (r2 = 0.68, P < 0.001). High bedaquiline adherence (≥90%) compared with lower adherence was associated with improved end of treatment successful outcome (83.4% vs. 46.3%, P < 0.001), decreased mortality (11.0% vs. 29.6% P = 0.004), and improved retention in care through end of treatment (94.5% vs. 79.6% P = 0.002). Modeling identified a highly significant but linear association between bedaquiline adherence and outcome. On multivariable analysis, bedaquiline adherence was independently associated with mortality and outcome. Bedaquiline resistance-associated variants were seen in 12% (7/57) of sequenced isolates (7% baseline, 5% emergent) with only 28.6% experiencing successful treatment outcome. CONCLUSIONS Bedaquiline adherence through 6 months independently predicted end of MDR-TB treatment outcome, but a specific bedaquiline adherence threshold was not identified. Interventions to optimize bedaquiline adherence are urgently needed to improve MDR-TB HIV treatment outcomes.
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Affiliation(s)
- Max R O’Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine
- Department of Epidemiology, Columbia University Medical Center, New York City, USA
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Nesri Padayatchi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Allison Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York City, USA
| | - Jennifer Zelnick
- Graduate School of Social Work, Touro College and University System, New York City, USA
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University Toronto, Canada
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | | | - Camus Nimmo
- Division of Infection and Immunity, University College London, London, UK
- UCL Genetics Institute, University College London, London, UK
- Africa Health Research Institute, Durban, South Africa
| | - Matt Baldwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York City, USA
| | - Resha Boodhram
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Bhavna Maharaj
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - K. Rivet Amico
- University of Michigan School of Public Health, Ann Arbor, MI, USA
- Kogieleum Naidoo CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
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Abstract
BACKGROUND Adherence to prescribed analgesics for patients seriously ill with cancer pain is essential for comfort. OBJECTIVE The objective of this study was to determine the analgesic adherence in seriously ill patients with cancer and its association with clinical and demographic characteristics. METHODS This is a cross-sectional study. At home, 202 patients with cancer (mean age, 59.9 ± 14.2 years; 58% female, 48% Black, and 42% White) admitted to hospice/palliative care completed measures on a pen tablet: PAIN Report It, Symptom Distress Scale, mood state item, Pittsburgh Sleep Quality Index item, and Pain Management Index. RESULTS The mean current pain intensity was 4.4 ± 2.9, and the mean worst pain in the past 24 hours was 7.2 ± 2.7. More than one-half of participants were not satisfied with their pain level (54%) and reported their pain was more intense than they wanted to tolerate for 18 hours or longer in the last 24 hours (51%). Only 12% were not prescribed analgesics appropriate for the intensity of their pain. Adherence rates were variable: nonsteroidal anti-inflammatory drugs (0.63 ± 0.50), adjuvants (0.93 ± 0.50), World Health Organization step 2 opioids (0.63 ± 0.49), and step 3 opioids (0.80 ± 0.40). With setting/clinical/demographic variables in the model, dose intervals of less than 8 hours were associated with less adherence ( P < .001). CONCLUSION Little progress has been made toward improving analgesic adherence even in settings providing analgesics without cost. Research focused on targeting analgesic dose intervals and barriers not related to cost is needed. IMPLICATION FOR PRACTICE Dose intervals of 8 hours or longer were significantly associated with higher adherence rates; therefore, use of longer-acting analgesics is one strategy to improve pain control at the end of life.
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14
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Acosta J, Flores P, Alarcón M, Grande-Ortiz M, Moreno-Exebio L, Puyen ZM. A randomised controlled trial to evaluate a medication monitoring system for TB treatment. Int J Tuberc Lung Dis 2022; 26:44-49. [PMID: 34969428 PMCID: PMC8734191 DOI: 10.5588/ijtld.21.0373] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: Adherence to TB treatment and therefore treatment success could be improved using digital adherence technology.OBJECTIVE: To evaluate the effectiveness of a medication event reminder monitor system (MERM) on treatment success and treatment adherence in patients with drug-susceptible pulmonary TB in Perú.METHODS: This was an experimental, randomised, open-label, controlled study conducted among patients in the second phase of TB treatment. The intervention group received their medications through MERM with the support of a treatment monitor, whereas the control group used the usual strategy. Participants were followed until they completed the 54 doses of the second phase of treatment.RESULTS: The study included 53 patients in each group; four in the intervention group withdrew from the study. Treatment success was significantly more frequent in the MERM group (RR 1.15, 95% CI 1.02-1.30; P = 0.0322). There was no significant difference in the adherence outcomes; however, the percentage of patients who missed at least one dose and patients with more than 10% of total doses missed were lower in the intervention group.CONCLUSION: The use of MERM in the second phase of treatment showed a significant improvement in the treatment success rate in patients with drug-susceptible pulmonary TB.
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Affiliation(s)
- J Acosta
- Facultad de Medicina Humana, Universidad Nacional del Centro del Perú, Huancayo, Peru
| | - P Flores
- Instituto Nacional de Salud, Lima, Peru
| | - M Alarcón
- Instituto Nacional de Salud, Lima, Peru
| | | | | | - Z M Puyen
- Instituto Nacional de Salud, Lima, Peru, Escuela de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
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15
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Thomas BE, Kumar JV, Periyasamy M, Khandewale AS, Hephzibah Mercy J, Raj EM, Kokila S, Walgude AS, Gaurkhede GR, Kumbhar JD, Ovung S, Paul M, Rajkumar BS, Subbaraman R. Acceptability of the Medication Event Reminder Monitor for Promoting Adherence to Multidrug-Resistant Tuberculosis Therapy in Two Indian Cities: Qualitative Study of Patients and Health Care Providers. J Med Internet Res 2021; 23:e23294. [PMID: 34110300 PMCID: PMC8262665 DOI: 10.2196/23294] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/27/2020] [Accepted: 04/30/2021] [Indexed: 01/22/2023] Open
Abstract
Background Patients with multidrug-resistant tuberculosis (MDR-TB) face challenges adhering to medications, given that treatment is prolonged and has a high rate of adverse effects. The Medication Event Reminder Monitor (MERM) is a digital pillbox that provides pill-taking reminders and facilitates the remote monitoring of medication adherence. Objective This study aims to assess the MERM’s acceptability to patients and health care providers (HCPs) during pilot implementation in India’s public sector MDR-TB program. Methods From October 2017 to September 2018, we conducted qualitative interviews with patients who were undergoing MDR-TB therapy and were being monitored with the MERM and HCPs in the government program in Chennai and Mumbai. Interview transcripts were independently coded by 2 researchers and analyzed to identify the emergent themes. We organized findings by using the Unified Theory of Acceptance and Use of Technology (UTAUT), which outlines 4 constructs that predict technology acceptance—performance expectancy, effort expectancy, social influence, and facilitating conditions. Results We interviewed 65 patients with MDR-TB and 10 HCPs. In patient interviews, greater acceptance of the MERM was related to perceptions that the audible and visual reminders improved medication adherence and that remote monitoring reduced the frequency of clinic visits (performance expectancy), that the device’s organization and labeling of medications made it easier to take them correctly (effort expectancy), that the device facilitated positive family involvement in the patient’s care (social influences), and that remote monitoring made patients feel more cared for by the health system (facilitating conditions). Lower patient acceptance was related to problems with the durability of the MERM’s cardboard construction and difficulties with portability and storage because of its large size (effort expectancy), concerns regarding stigma and the disclosure of patients’ MDR-TB diagnoses (social influences), and the incorrect understanding of the MERM because of suboptimal counseling (facilitating conditions). In their interviews, HCPs reported that MERM implementation resulted in fewer in-person interactions with patients and thus allowed HCPs to dedicate more time to other tasks, which improved job satisfaction. Conclusions Several features of the MERM support its acceptability among patients with MDR-TB and HCPs, and some barriers to patient use could be addressed by improving the design of the device. However, some barriers, such as disease-related stigma, are more difficult to modify and may limit use of the MERM among some patients with MDR-TB. Further research is needed to assess the accuracy of MERM for measuring adherence, its effectiveness for improving treatment outcomes, and patients’ sustained use of the device in larger scale implementation.
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Affiliation(s)
- Beena E Thomas
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - J Vignesh Kumar
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Murugesan Periyasamy
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Amit Subhash Khandewale
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - J Hephzibah Mercy
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - E Michael Raj
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - S Kokila
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Apurva Shashikant Walgude
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Gunjan Rahul Gaurkhede
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Jagannath Dattatraya Kumbhar
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Senthanro Ovung
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Mariyamma Paul
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - B Sathyan Rajkumar
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States.,Center for Global Public Health, Tufts University School of Medicine, Boston, MA, United States.,Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA, United States
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Ngowi K, Pima F, Mmbaga BT, Aarnoutse RE, Reiss P, Nieuwkerk PT, Sprangers M, Sumari-de Boer M. "I Wish to Continue Receiving the Reminder Short Messaging Service": A Mixed Methods Study on the Acceptability of Digital Adherence Tools Among Adults Living with HIV on Antiretroviral Treatment in Tanzania. Patient Prefer Adherence 2021; 15:559-568. [PMID: 33727801 PMCID: PMC7955743 DOI: 10.2147/ppa.s290079] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/06/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Digital Adherence Tools (DAT) to promote adherence to antiretroviral treatment (ART) for HIV are being increasingly adopted globally, however their effectiveness and acceptability in limited resource settings has been challenging. In this study, we examine the acceptability of DATs to improve adherence to ART. METHODS This study was part of a three-arm randomized controlled trial (REMIND) which investigated the effect of two different DAT's: SMS text messages (SMS) or real-time medication monitoring (RTMM) on treatment adherence; compared to standard of care. Exit interviews and in-depth interviews were conducted at 48 weeks follow-up, to collect data on their experiences (successes, challenges, and barriers) and behaviours regarding the implementation of the interventions. Translated transcripts, memos and field notes were imported to NVivo software version 12. We used a thematic framework analysis which drew from Sekhon's theoretical framework of acceptability (TFA), which comprises of seven constructs (affective attitude, perceived burden, perceived effectiveness, ethicality, self-efficacy, intervention coherence and opportunity costs). RESULTS Of the 166 participants enrolled, 143 (86%) were interviewed (68 in the SMS arm and 75 in the RTMM arm). Participants were highly satisfied (98%) with the DAT system and the majority of them reported it motivated them to take their medication (99%). The majority of participants reported they were confident in their ability to comply with the intervention and understood how the intervention worked (97%). Very few reported negatively about the devices (carrying the device), with only 6% reporting that they did not feel comfortable and 8% had ethical concerns with the SMS-content A few participants reported challenges with their connectivity/network and that the visits were too time-consuming. A few participants reported that they incurred extra cost for the sake of the study. CONCLUSION Overall, the acceptability of these DATs was high. However, several factors may hamper their acceptability including the content and number of SMS, carrying the devices and the network availability.
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Affiliation(s)
- Kennedy Ngowi
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Amsterdam UMC, Location AMC, University of Amsterdam, Department of Medical Psychology, Amsterdam, The Netherlands
| | - Francis Pima
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Blandina Theophil Mmbaga
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Rob E Aarnoutse
- Radboudumc, Radboud Institute for Health Sciences & Department of Pharmacy, Nijmegen, The Netherlands
| | - Peter Reiss
- Amsterdam UMC, Location AMC, University of Amsterdam, Department of Global Health, And Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- HIV Monitoring Foundation, Amsterdam, The Netherlands
| | - Pythia T Nieuwkerk
- Amsterdam UMC, Location AMC, University of Amsterdam, Department of Medical Psychology, Amsterdam, The Netherlands
| | - Mirjam Sprangers
- Amsterdam UMC, Location AMC, University of Amsterdam, Department of Medical Psychology, Amsterdam, The Netherlands
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Rattanapiratanon A, Kongsomboon K, Hanprasertpong T. Efficacy of a 28-compartment pillbox for improving iron supplement compliance in healthy pregnant women: a randomised controlled trial. J OBSTET GYNAECOL 2021; 41:1210-1215. [PMID: 33645407 DOI: 10.1080/01443615.2020.1856056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
A randomised controlled trial was conducted. The primary objective was to evaluate the efficacy of a pillbox for increasing iron supplement compliance by comparing the proportion of pregnant women who had no remaining iron tablets between pregnant women attending ANC who were given a pillbox to use and women with no pillbox in four-week period between ANC visits. The secondary objective was to evaluate the reasons for poor compliance and possible factors associated with the non-compliance. One hundred and ninety pregnant women were enrolled, 95 participants were randomised into each of the groups. The proportion of pregnant women who had no remaining iron tablets at the end was statistically significantly lower in the pillbox group than in the control group [53.3% and 23.1%, respectively, p < .001, RR2.308 (95% CI 1.515 - 3.517)]. The most common reason given for having of iron tablets remaining was forgetfulness. The visual analog scale (VAS) scores indicated that patient's responsibility feeling, duration of sleep each day and presence of a handicapped or small child in care significantly influenced the proportion of pregnant women who had remaining iron tablets at the end in both groups. We concluded that a pillbox was found to be an effective tool for improving pregnant women's compliance with taking their iron supplements.IMPACT STATEMENTWhat is already known about this subject? Antenatal care (ANC) influences maternal and neonatal outcomes. The incidence of anaemia in pregnant women is reported to be around 42% and approximately 50% result from iron deficiency. Maternal anaemia increases the risk of foetal low birth weight, preterm birth, perinatal mortality, stillbirth and maternal mortality.What do the results of this study add? The 28-compartment pillbox is effective for improving iron supplement compliance in healthy pregnant women. Forgetfulness is the most common reason given for having remaining iron tablets. The lower score on the visual analog scale of patient's feeling of responsibility, long duration of sleep a day and the presence of a handicapped or small child in their care were significantly associated with having remaining iron tablets.What are the implications are of these finding for clinical practice and/or further research? The 28-compartment pillbox can be implied to routine antenatal care for improving iron supplement compliance in healthy pregnant women. Health care providers should be reminded to encourage compliance with iron supplement prescription in pregnant women who are at risk of poor compliance as indicated by low VAS of the patient's feeling of responsibility, long duration of sleep in a day and pregnant women who have responsibility to take care of handicapped or small children.
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Affiliation(s)
- Athiwat Rattanapiratanon
- Department of Obstetrics and Gynecology, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Thailand
| | - Kittipong Kongsomboon
- Department of Preventive and Social Medicine, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Thailand
| | - Tharangrut Hanprasertpong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Thailand
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Approaches to Objectively Measure Antiretroviral Medication Adherence and Drive Adherence Interventions. Curr HIV/AIDS Rep 2020; 17:301-314. [PMID: 32424549 PMCID: PMC7363551 DOI: 10.1007/s11904-020-00502-5] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Traditional methods to assess antiretroviral adherence, such as self-report, pill counts, and pharmacy refill data, may be inaccurate in determining actual pill-taking to both antiretroviral therapy (ART) or pre-exposure prophylaxis (PrEP). HIV viral loads serve as surrogates of adherence on ART, but loss of virologic control may occur well after decreases in adherence and viral loads are not relevant to PrEP. RECENT FINDINGS Pharmacologic measures of adherence, electronic adherence monitors, and ingestible electronic pills all serve as more objective metrics of adherence, surpassing self-report in predicting outcomes. Pharmacologic metrics can identify either recent adherence or cumulative adherence. Recent dosing measures include antiretroviral levels in plasma or urine, as well as emtricitabine-triphosphate in dried blood spots (DBS) for those on tenofovir-emtricitabine-based therapy. A urine tenofovir test has recently been developed into a point-of-care test for bedside adherence monitoring. Cumulative adherence metrics assess adherence over weeks to months and include measurement of tenofovir-diphosphate in peripheral blood mononuclear cells or DBS, as well as ART levels in hair. Electronic adherence monitors and ingestible electronic pills can track pill bottle openings or medication ingestion, respectively. New and objective approaches in adherence monitoring can be used to detect nonadherence prior to loss of prevention efficacy or virologic control with PrEP or ART, respectively.
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Zelnick JR, Daftary A, Hwang C, Labar AS, Boodhram R, Maharaj B, Wolf AK, Mondal S, Amico KR, Orrell C, Seepamore B, Friedland G, Padayatchi N, O'Donnell MR. Electronic dose monitoring identifies a high-risk subpopulation in the treatment of drug-resistant tuberculosis and HIV. Clin Infect Dis 2020; 73:e1901-e1910. [PMID: 33053186 DOI: 10.1093/cid/ciaa1557] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND In generalized drug-resistant tuberculosis (DR-TB) HIV epidemics, identifying subpopulations at high risk for treatment failure and loss to care is critically important to improve treatment outcomes and prevent amplification of drug resistance. We hypothesized that an electronic dose-monitoring (EDM) device could empirically identify adherence-challenged patients and that a mixed-methods approach would characterize treatment challenges. METHODS A prospective study of DR-TB HIV patients on antiretroviral therapy (ART) initiating bedaquiline-containing regimens in KwaZulu-Natal, South Africa. Separate EDM devices measured adherence for bedaquiline and ART. Patients with low adherence (<85%) to both bedaquiline and ART were identified as high-risk for poor outcomes. Baseline survey, study visit notes and focus group discussions characterized treatment challenges. RESULTS From December 2016-February 2018, 32 of 198 (16%) enrolled DR-TB HIV patients were identified as dual adherence-challenged. In a multivariate model including baseline characteristics, only receiving a disability grant was significantly associated with dual non-adherence at 6-months. Mixed-methods identified treatment barriers including, alcohol abuse, family conflicts, and mental health issues. Compared to adherent patients, dual-adherence challenged patients struggled to prioritize treatment and lacked support, and dual adherence-challenged patients experienced higher rates of detectable HIV viral load and mortality compared to more adherent patients. CONCLUSION EDM empirically identified a subpopulation of DR-TB HIV patients with dual adherence challenges early in treatment. Mixed-methods revealed intense psychosocial, behavioral, and structural barriers to care in this subpopulation. Our data supports developing differential, patient-centered, adherence support interventions focused on psychosocial and structural challenges for subpopulations of at-risk DR-TB HIV patients.
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Affiliation(s)
- Jennifer R Zelnick
- Graduate School of Social Work, Touro College and University System, NY, NY USA
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, Ontario Canada.,CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Christina Hwang
- Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, NY, NY, USA
| | - Amy S Labar
- Vagelos College of Physician & Surgeons, Columbia University, NY, NY USA
| | - Resha Boodhram
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Bhavna Maharaj
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Allison K Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, NY, NY, USA
| | - Shinjini Mondal
- Department of Family Medicine, McGill University, Montreal, Canada
| | - K Rivet Amico
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, South Africa
| | | | | | - Nesri Padayatchi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Max R O'Donnell
- Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, NY, NY, USA.,CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, NY, NY, USA
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20
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Nguyen C, Dew MA, Irizarry T, McNulty M, Rennick J, Knäuper B, Descoteaux A, Grenier A, Jeannot L, Foster BJ, DeVito Dabbs AJ. Promoting medication adherence from the perspective of adolescent and young adult kidney transplant recipients, parents, and health care professionals: A TAKE-IT TOO study. Pediatr Transplant 2020; 24:e13709. [PMID: 32388916 PMCID: PMC7392786 DOI: 10.1111/petr.13709] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/10/2020] [Accepted: 03/03/2020] [Indexed: 12/30/2022]
Abstract
Medication non-adherence is an important factor limiting allograft survival after kidney transplantation in AYA. Some interventions, including the TAKE-IT, showed some success in promoting adherence but the potential for scalability and use in routine clinical practice is limited. We applied user-centered design to gather the perspectives of recipients, parents, and health professionals concerning their needs, challenges, and potential intervention strategies to design an optimal, multi-component medication adherence intervention. The qualitative study was conducted at four Canadian and three American kidney transplant programs. Separate focus groups for recipients, parents, and health professionals were convened to explore these stakeholders' perspectives. Directed content analysis was employed to identify themes that were shared vs distinct across stakeholders. All stakeholder groups reported challenges related to taking medications on time in the midst of their busy schedules and the demands of transitioning toward independence during adolescence. The stakeholders also made suggestions for the multi-component behavioral intervention, including an expanded electronic pillbox and companion website, education materials, and customized digitized features to support shared responsibility and communication among recipients, parents, and health professionals. Several suggestions regarding the functionality and features of the potential intervention reported in this early stage will be explored in more depth as the iterative process unfolds. Our approach to actively involve all stakeholders in the process increases the likelihood of designing an adherence intervention that is truly user-informed and fit for the clinical setting.
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Affiliation(s)
- Christina Nguyen
- UH Rainbow Babies and Children’s Hospital Division of Pediatrics, Division of Pediatric Nephrology, Cleveland, OH, USA
| | - Mary Amanda Dew
- University of Pittsburgh School of Medicine, Psychiatry Pittsburgh, PA, USA
| | - Taya Irizarry
- University of Pittsburgh School of Nursing, Acute and Tertiary Care Pittsburgh, PA, USA
| | - Mary McNulty
- University of Pittsburgh School of Medicine, Psychiatry Pittsburgh, PA, USA
| | - Janet Rennick
- Research Institute of the McGill University Health Centre Montreal, QC, CAN
| | | | - Annie Descoteaux
- Centre Hospitalier Universitaire Ste. Justine, Montreal, QC, CAN
| | | | - Lovemine Jeannot
- Research Institute of the McGill University Health Centre Montreal, QC, CAN
| | - Bethany J Foster
- Research Institute of the McGill University Health Centre Montreal, QC, CAN
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Ngowi KM, Lyamuya F, Mmbaga BT, Muro E, Hillu Z, Shirima M, Aarnoutse RE, Ag Sprangers M, Nieuwkerk PT, Reiss P, Sumari-de Boer M. Technical and Psychosocial Challenges of mHealth Usage for Antiretroviral Therapy Adherence Among People Living With HIV in a Resource-Limited Setting: Case Series. JMIR Form Res 2020; 4:e14649. [PMID: 32519966 PMCID: PMC7315367 DOI: 10.2196/14649] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 11/23/2022] Open
Abstract
Background Mobile communication has been found to improve antiretroviral therapy (ART) adherence among people living with HIV. In an ongoing randomized clinical trial, 2 mobile communication strategies (ie, sending SMS text messages and real-time medication monitoring [RTMM]) were used to improve adherence to ART among people living with HIV in Tanzania. We noticed remarkable discrepancies between self-reported adherence and adherence recorded by SMS text messaging or RTMM among some of the first trial participants. Objective Our objective was to describe these cases and the observed discrepancies in more detail, to serve as a useful illustration of some of the challenges in using mobile health in resource-limited settings. Methods In an ongoing randomized trial, adults living with HIV from two HIV treatment centers in Tanzania who were suspected of low levels of adherence were randomly assigned in a 1:1:1 ratio to receive (1) SMS text message reminders, (2) an RTMM device, or (3) no additional intervention to standard HIV care. During bimonthly study visits, the participants self-reported their level of adherence, received feedback about their level of adherence based on SMS text messaging or RTMM, and discussed strategies to overcome adherence problems with nurses providing HIV care. For the purpose of this report, we selected people living with HIV who had completed 5 follow-up visits and consistently reported more than 95% adherence, while SMS text messaging or RTMM recorded lower than 75% adherence. The participants were invited for a short, face-to-face in-depth interview to explore reasons for this discrepancy. Results At the time of this analysis, 26 participants had completed follow-up. Six of these evidenced the above-mentioned discrepancies, with an average adherence of 46% based on SMS text messaging or RTMM, while self-reported adherence was 98%. Five of these 6 participants insisted that their adherence to ART was good, with 4 reporting that their adherence to properly using the monitoring device was low. Three participants mentioned concerns about involuntary disclosure of HIV status as a main reason for low adherence to using the device. Two participants were still depending on other reminder cues despite receiving SMS text message or RTMM reminders. Poor network coverage caused low adherence in 1 participant. Conclusions Psychosocial barriers were reported as importantly contributing to low adherence, both with respect to use of ART and proper use of the adherence-monitoring device. This case series illustrates that when introducing new digital adherence monitoring technology, researchers should consider psychosocial barriers and distinguish between adherence to device use and adherence to treatment. Trial Registration Pan African Clinical Trials Registry PACTR201712002844286; https://tinyurl.com/y98q4p3l
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Affiliation(s)
- Kennedy Michael Ngowi
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania.,Department of Medical Psychology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Furaha Lyamuya
- Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania.,Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania.,Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
| | - Eva Muro
- Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania.,Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
| | - Zawadiel Hillu
- Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Mary Shirima
- Majengo Dispensary, Moshi, United Republic of Tanzania
| | - Rob E Aarnoutse
- Radboud Institute for Health Sciences & Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Mirjam Ag Sprangers
- Department of Medical Psychology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Pythia T Nieuwkerk
- Department of Medical Psychology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Peter Reiss
- Department of Global Health and Division of infectious Diseases, Amsterdam institute of Global Health and Development, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Stichting HIV Monitoring, Hogeschool van Amsterdam, Amsterdam, Netherlands
| | - Marion Sumari-de Boer
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
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22
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O'Donnell MR, Padayatchi N, Daftary A, Orrell C, Dooley KE, Rivet Amico K, Friedland G. Antiretroviral switching and bedaquiline treatment of drug-resistant tuberculosis HIV co-infection. Lancet HIV 2020; 6:e201-e204. [PMID: 30846058 DOI: 10.1016/s2352-3018(19)30035-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 01/18/2019] [Accepted: 01/29/2019] [Indexed: 01/07/2023]
Abstract
Bedaquiline, a potent new therapy for drug-resistant tuberculosis, results in improved survival including in HIV patients with multidrug and extensively drug-resistant tuberculosis. In line with WHO recommendations, in South Africa and other low-income and middle-income settings, antiretroviral therapy is switched from generic fixed-dose combination efavirenz-containing regimens to twice-daily nevirapine with separate companion pills because of interactions between efavirenz and bedaquiline. Early data suggest a signal for low antiretroviral therapy adherence after this antiretroviral therapy switch. Mortality and other tuberculosis-specific benefits noted with bedaquiline treatment in multidrug and extensively drug-resistant tuberculosis HIV might be compromised by HIV viral failure, and emergent antiretroviral resistance. Programmatic responses, such as adherence support and dual pharmacovigilance, should be instituted; antiretroviral therapy initiation with fixed-dose combinations without bedaquiline drug interactions should be strongly considered.
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Affiliation(s)
- Max R O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, and Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA; CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.
| | - Nesri Padayatchi
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Amrita Daftary
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa; McGill International TB Centre and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Catherine Orrell
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Division of Clinical Pharmacology and Infectious Diseases, Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - K Rivet Amico
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
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23
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MacCarthy S, Mendoza-Graf A, Saya U, Samba C, Birungi J, Okoboi S, Linnemayr S. Lessons learned from a mobile technology-based intervention informed by behavioral economics to improve ART adherence among youth in Uganda. AIDS Care 2020; 32:616-622. [PMID: 31137959 PMCID: PMC6999852 DOI: 10.1080/09540121.2019.1622630] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 05/14/2019] [Indexed: 12/12/2022]
Abstract
Evidence suggests that simple text messaging interventions may not suffice to improve ART adherence among youth in low-resource settings. To address this shortcoming, we developed an intervention that shared weekly real-time adherence feedback to youth in Uganda using short message services (SMS), based on information tracked by an electronic device (Wisepill). We present results from 7 formative and 6 exit focus groups (FGs) in Mulago and Entebbe, Uganda with youth ages 15-24, providers, and Community Advisory Board members. Participants consistently conveyed positive impressions of Wisepill, noting that it helped store their medications, facilitated travel, served as a reminder, and motivated adherence. Participants raised phone-related issues before the study; most were addressed but some remained (e.g., limited network access, electricity for powering phones). Further, they highlighted the importance of carefully crafting text messages (e.g., use slang rather than potentially stigmatizing words) and viewed personalizing messages favorably but were divided on the desirability of including their name in study-related texts. Exit FGs confirmed that sharing group adherence levels with participants tapped into the competitive spirit common among youth. Our results suggest future mobile technology-based interventions can be improved by providing messages that go beyond simple reminders to provide individual and group-level adherence feedback.
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Affiliation(s)
- Sarah MacCarthy
- RAND Corporation, Behavioral and Policy Sciences, Santa Monica, CA, USA
| | | | - Uzaib Saya
- Pardee RAND Graduate School, Santa Monica, CA, USA
| | | | | | - Stephen Okoboi
- Infectious Diseases Institute, Makerere University Kampala, Uganda
| | - Sebastian Linnemayr
- RAND Corporation, Economics, Sociology, and Statistics, Santa Monica, CA, USA
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24
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MacCarthy S, Wagner Z, Mendoza-Graf A, Gutierrez CI, Samba C, Birungi J, Okoboi S, Linnemayr S. A randomized controlled trial study of the acceptability, feasibility, and preliminary impact of SITA (SMS as an Incentive To Adhere): a mobile technology-based intervention informed by behavioral economics to improve ART adherence among youth in Uganda. BMC Infect Dis 2020; 20:173. [PMID: 32093630 PMCID: PMC7041095 DOI: 10.1186/s12879-020-4896-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 02/17/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Studies report serious adherence problems among youth (individuals age 15-24 years of age) in Uganda. Recent growth in mobile phone ownership has highlighted the potential of using text-based interventions to improve antiretroviral treatment (ART) adherence among Ugandan youth. We piloted a randomized controlled trial of a text-based intervention providing weekly real-time antiretroviral adherence feedback, based on information from a smart pill box, to HIV-positive Ugandan youth. In this paper, we report the acceptability, feasibility, and preliminary impact of the intervention. METHODS We randomized participants to a control group, or to receive messages with information on either their own adherence levels (Treatment 1 - T1), or their own adherence and peer adherence levels (Treatment 2 - T2). We conducted six focus groups from December 2016 to March 2017 with providers and youth ages 15-24, double coded 130 excerpts, and achieved a pooled Cohen's Kappa of 0.79 and 0.80 based on 34 randomly selected excerpts. RESULTS The quantitative and qualitative data show that the intervention was deemed acceptable and feasible. After controlling for baseline adherence, the T1 group had 3.8 percentage point lower adherence than the control group (95% CI -9.9, 2.3) and the T2 group had 2.4 percentage points higher adherence than the control group (95% CI -3.0, 7.9). However, there was an increasing treatment effect over time for the T2 group with the largest effect towards the end of the study; a 2.5 percentage point increase in the initial 9-weeks that grows steadily to 9.0 percentage points by the last 9-weeks of the study. We find negative treatment effects for T1 in 3 of the 4 9-week intervals. This pilot study was not designed to detect statistically significant differences. CONCLUSIONS Improving youth's adherence by supplementing information about their adherence with information about the adherence of peers is a promising new strategy that should be further evaluated in a fully-powered study. Providing one's own adherence information alone appears to have less potential. TRIAL REGISTRATION NCT02514356 07/30/2015.
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Affiliation(s)
- Sarah MacCarthy
- Behavioral and Policy Sciences, RAND Corporation, 1776 Main Street, Santa Monica, CA, USA.
| | - Zachary Wagner
- Economics, Sociology, Statistics, RAND Corporation, Santa Monica, CA, USA
| | | | | | | | | | - Stephen Okoboi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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25
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Lee Y, Raviglione MC, Flahault A. Use of Digital Technology to Enhance Tuberculosis Control: Scoping Review. J Med Internet Res 2020; 22:e15727. [PMID: 32053111 PMCID: PMC7055857 DOI: 10.2196/15727] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 02/06/2023] Open
Abstract
Background Tuberculosis (TB) is the leading cause of death from a single infectious agent, with around 1.5 million deaths reported in 2018, and is a major contributor to suffering worldwide, with an estimated 10 million new cases every year. In the context of the World Health Organization’s End TB strategy and the quest for digital innovations, there is a need to understand what is happening around the world regarding research into the use of digital technology for better TB care and control. Objective The purpose of this scoping review was to summarize the state of research on the use of digital technology to enhance TB care and control. This study provides an overview of publications covering this subject and answers 3 main questions: (1) to what extent has the issue been addressed in the scientific literature between January 2016 and March 2019, (2) which countries have been investing in research in this field, and (3) what digital technologies were used? Methods A Web-based search was conducted on PubMed and Web of Science. Studies that describe the use of digital technology with specific reference to keywords such as TB, digital health, eHealth, and mHealth were included. Data from selected studies were synthesized into 4 functions using narrative and graphical methods. Such digital health interventions were categorized based on 2 classifications, one by function and the other by targeted user. Results A total of 145 relevant studies were identified out of the 1005 published between January 2016 and March 2019. Overall, 72.4% (105/145) of the research focused on patient care and 20.7% (30/145) on surveillance and monitoring. Other programmatic functions 4.8% (7/145) and electronic learning 2.1% (3/145) were less frequently studied. Most digital health technologies used for patient care included primarily diagnostic 59.4% (63/106) and treatment adherence tools 40.6% (43/106). On the basis of the second type of classification, 107 studies targeted health care providers (107/145, 73.8%), 20 studies targeted clients (20/145, 13.8%), 17 dealt with data services (17/145, 11.7%), and 1 study was on the health system or resource management. The first authors’ affiliations were mainly from 3 countries: the United States (30/145 studies, 20.7%), China (20/145 studies, 13.8%), and India (17/145 studies, 11.7%). The researchers from the United States conducted their research both domestically and abroad, whereas researchers from China and India conducted all studies domestically. Conclusions The majority of research conducted between January 2016 and March 2019 on digital interventions for TB focused on diagnostic tools and treatment adherence technologies, such as video-observed therapy and SMS. Only a few studies addressed interventions for data services and health system or resource management.
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Affiliation(s)
- Yejin Lee
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Mario C Raviglione
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland.,Centre for Multidisciplinary Research in Health Science (MACH), Università di Milano, Milan, Italy
| | - Antoine Flahault
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland
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Arnet I, Rothen JP, Albert V, Hersberger KE. Validation of a Novel Electronic Device for Medication Adherence Monitoring of Ambulatory Patients. PHARMACY 2019; 7:pharmacy7040155. [PMID: 31756904 PMCID: PMC6958479 DOI: 10.3390/pharmacy7040155] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 12/31/2022] Open
Abstract
Several methods exist for measuring medication adherence. The Time4MedTM device (Adherence Innovations, Hong Kong) is a small, electronic card to affix on medication packaging that records date and time of intakes when a button is pushed. We aimed to validate the device with an emphasis on polypharmacy. Twenty volunteers used Time4MedTM devices with a virtual thrice daily intake over 14 days. Diary-recorded date and time were compared to electronically-stored events. Functionality, reliability and recovery for different stress conditions were calculated. User‘s acceptability was assessed with the System Usability Scale (SUS). Eleven elderly outpatients (mean age 80.2 ± 8.1 years) taking >3 medications daily used the device over 4 weeks. Volunteers logged 847 events. Functionality (100%), sensitivity (94.9%), specificity (99.4%) and recovery (100%) were high. Dropping the smart card and storing it in a refrigerator caused either the recording of false events or no recording at all. The mean SUS score was 82.6 (SD 14.8), demonstrating excellent acceptability. Satisfaction was very high for volunteers and patients, except for pushing the button. Time4MedTM devices are highly accurate in recording, retaining and delivering electronic data of multiple medication intake. They are well accepted by elderly patients. They can be recommended in clinical studies and for practitioners who desire to elucidate adherence patterns of ambulatory patients.
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Drabarek D, Anh NT, Nhung NV, Hoa NB, Fox GJ, Bernays S. Implementation of Medication Event Reminder Monitors among patients diagnosed with drug susceptible tuberculosis in rural Viet Nam: A qualitative study. PLoS One 2019; 14:e0219891. [PMID: 31329610 PMCID: PMC6645511 DOI: 10.1371/journal.pone.0219891] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 07/04/2019] [Indexed: 12/18/2022] Open
Abstract
Background Despite the criticality of adherence to tuberculosis treatment, there is paucity of rigorous experimental research exploring the efficacy of interventions to promote adherence and a greater lack of inquiry addressing the integral role of adherence behaviour. The aim of this formative study was to examine the way in which the Wisepill evriMED Medication Event Reminder Monitor (MERM) was used among outpatients with drug susceptible pulmonary tuberculosis. Methods In depth interviews were conducted with 20 outpatients receiving treatment from two public healthcare facilities in Thanh Hoa, a rural province in northern Viet Nam. Patients had been enrolled in a randomized controlled trial evaluating the effect of using the MERM device upon adherence for between 1–3 months. The control group used the device without an alert, while the intervention group used the device with a daily alert and scheduled dosing history review. Findings All 20 patients interviewed were supportive of using the MERM device. Those able to be at home at the time that their treatment was due (50%) used the device as intended. Patients who worked all reported separating the time when the box was opened from the time at which they ingested their medication. Patients expressed fidelity to the prescribed medication taking time and concerns regarding the portability of the device. Limitations of the study surround the inclusion of a small sample population that did not experience factors that further compromise adherence. Conclusions Data recorded by the box did not always accurately reflect usage patterns. The alert in the intervention arm was able to support adherence only in patients who did not work while completing their treatment. MERM implementation can be improved by better aligning prescriber instructions with patients’ daily routines, and increasing the use of adherence data to guide adherence support practices. Healthcare staff need to be aware of potential barriers to optimal use of MERM devices. A rigorous qualitative approach to formative assessment is essential to inform the scale up of new digital technologies.
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Affiliation(s)
- Dorothy Drabarek
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- * E-mail:
| | - Nguyen T. Anh
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | | | | | - Greg J. Fox
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Sarah Bernays
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Sumari-de Boer M, Pima FM, Ngowi KM, Chelangwa GM, Mtesha BA, Minja LM, Semvua HH, Mpagama S, Mmbaga BT, Nieuwkerk PT, Aarnoutse RE. Implementation and effectiveness of evriMED with short messages service (SMS) reminders and tailored feedback compared to standard care on adherence to treatment among tuberculosis patients in Kilimanjaro, Tanzania: proposal for a cluster randomized controlled trial. Trials 2019; 20:426. [PMID: 31300028 PMCID: PMC6626331 DOI: 10.1186/s13063-019-3483-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adherence to tuberculosis (TB) treatment is challenging because of many factors. The World Health Organization has recommended the use of digital adherence monitoring technologies in its End TB Strategy. However, evidence on improving adherence is limited. EvriMED is a real-time medication-monitoring device which was found to be feasible and acceptable in a few studies in Asia. In Tanzania, however, there may be challenges in implementing evriMED due to stigmatization, network and power access, accuracy, and cost effectiveness, which may have implications for treatment outcome. We propose a pragmatic cluster randomized trial to investigate the effectiveness of evriMED with reminder cues and tailored feedback on adherence to TB treatment in Kilimanjaro, Tanzania. METHODS/DESIGN We will create clusters in Kilimanjaro based on level of health care facility. Clusters will be randomized in an intervention arm, where evriMED will be implemented, or a control arm, where standard practice directly observed treatment will be followed. TB patients in intervention clusters will take their medication from the evriMED pillbox and receive tailored feedback. We will use the 'Stages of Change' model, which assumes that a person has to go through the stages of pre-contemplation, contemplation, preparation, action, and evaluation to change behavior for tailored feedback on adherence reports from the device. DISCUSSION If the intervention shows a significant effect on adherence and the devices are accepted, accurate, and sustainable, the intervention can be scaled up within the National Tuberculosis Programmes. TRIAL REGISTRATION Pan African Clinical Trials Registry, PACTR201811755733759 . Registered on 8 November 2018.
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Affiliation(s)
- Marion Sumari-de Boer
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania. .,Department of International Health, RadboudUMC, Nijmegen, the Netherlands.
| | - Francis M Pima
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
| | - Kennedy M Ngowi
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania.,Department of Medical Psychology, Amsterdam UMC, Amsterdam, the Netherlands.,Medical psychologypsychology, AMC, AZ, 9 1105, Meibergdreef, Amsterdam, Netherlands
| | | | - Benson A Mtesha
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
| | - Linda M Minja
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
| | - Hadija H Semvua
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
| | - Stella Mpagama
- Kibong'oto Infectious Diseases Hospital, Sanya Juu, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
| | - Pythia T Nieuwkerk
- Department of Medical Psychology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Rob E Aarnoutse
- Department of Clinical Pharmacology, RadboudUMC, Nijmegen, the Netherlands
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MacCarthy S, Mendoza-Graf A, Huang H, Mukasa B, Linnemayr S. Supporting Adolescents to Adhere (SATA): Lessons learned from an intervention to achieve medication adherence targets among youth living with HIV in Uganda. CHILDREN AND YOUTH SERVICES REVIEW 2019; 102:56-62. [PMID: 31223179 PMCID: PMC6586245 DOI: 10.1016/j.childyouth.2019.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Youth in Uganda are disproportionately impacted by HIV and report significant barriers to ART adherence. We asked participants how fixed versus flexible adherence target setting for incentive interventions, in combination with other support systems, could help HIV-positive youth in Uganda reach medication adherence targets. METHODS Four focus groups conducted in Luganda were audiotaped, transcribed, and translated into English; the transcriptions were then coded using Dedoose software. Two members of the research team read the text and identified the basic topics covered. A codebook was developed that detailed inclusion and exclusion criteria for each topic area, as well as typical entries for each code. A directed content analysis was used to identify key themes. RESULTS Several themes were common across groups. Participants consistently maintained that they preferred to set their own adherence targets. But regardless of how adherence targets were assigned, participants noted that missing their target was disappointing. They commented positively on the use of Medication Event Monitoring System (MEMS) caps, noting that knowing their adherence information was being tracked often encouraged them to take their medications. Participants reported that receiving text messages further motivated them to take their medications; however, on occasions when they reported not doing well, they wanted intensive follow-up by staff. Participants said that the prize drawing alone did not motivate their ART adherence and that receiving 'zero' in the drawing was disheartening. CONCLUSION We found that participants preferred to set their own adherence targets and that doing so increased a sense of ownership in achieving them. All participants enjoyed using MEMS caps and expressed disappointment at needing to return the device at the study's completion. Participants noted that text message reminders may be a useful way to help patients stay motivated between clinic visits; however, ongoing engagement and support are needed from providers and counselors. Finally, our participants stressed the importance of including incentives with a small, positive value rather than 0 when designing the lowest prize.
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Affiliation(s)
- Sarah MacCarthy
- RAND Corporation, Behavioral and Policy Sciences, 1776 Main Street, Santa Monica, CA USA
| | | | - Haijing Huang
- RAND Corporation, 1776 Main Street, Santa Monica, CA USA
| | - Barbara Mukasa
- Mildmay, Uganda, 12 Km Entebbe Road, Naziba Hill, Lweza, Kampala, Uganda
| | - Sebastian Linnemayr
- RAND Corporation, Economics, Sociology, and Statistics, 1776 Main Street, Santa Monica, CA USA
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Subbaraman R, de Mondesert L, Musiimenta A, Pai M, Mayer KH, Thomas BE, Haberer J. Digital adherence technologies for the management of tuberculosis therapy: mapping the landscape and research priorities. BMJ Glob Health 2018; 3:e001018. [PMID: 30364330 PMCID: PMC6195152 DOI: 10.1136/bmjgh-2018-001018] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/13/2018] [Accepted: 09/14/2018] [Indexed: 11/15/2022] Open
Abstract
Poor medication adherence may increase rates of loss to follow-up, disease relapse and drug resistance for individuals with active tuberculosis (TB). While TB programmes have historically used directly observed therapy (DOT) to address adherence, concerns have been raised about the patient burden, ethical limitations, effectiveness in improving treatment outcomes and long-term feasibility of DOT for health systems. Digital adherence technologies (DATs)-which include feature phone-based and smartphone-based technologies, digital pillboxes and ingestible sensors-may facilitate more patient-centric approaches for monitoring adherence, though available data are limited. Depending on the specific technology, DATs may help to remind patients to take their medications, facilitate digital observation of pill-taking, compile dosing histories and triage patients based on their level of adherence, which can facilitate provision of individualised care by TB programmes to patients with varied levels of risk. Research is needed to understand whether DATs are acceptable to patients and healthcare providers, accurate for measuring adherence, effective in improving treatment outcomes and impactful in improving health system efficiency. In this article, we describe the landscape of DATs that are being used in research or clinical practice by TB programmes and highlight priorities for research.
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Affiliation(s)
- Ramnath Subbaraman
- Department of Public Health and Community Medicine and Tufts Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, USA
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Laura de Mondesert
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Angella Musiimenta
- Department of Information Technology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Beena E Thomas
- Department of Social and Behavioural Research, National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Jessica Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
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