1
|
Chen X, Zhou J, Yuan Q, Huang C, Li Y. A conceptual framework on determinants of the integrated tuberculosis control model implementation in China. Front Med (Lausanne) 2024; 11:1407131. [PMID: 39234037 PMCID: PMC11371783 DOI: 10.3389/fmed.2024.1407131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 07/22/2024] [Indexed: 09/06/2024] Open
Abstract
Improving the provision of tuberculosis (TB) care is both urgent and imperative to achieve the goals outlined in the End TB Strategy. China has initiated the integrated TB control model to enhance the quality of TB care Since 2012. Despite these efforts, the integrated TB control health system encounters numerous challenges in delivering effective TB care. The factors influencing TB care provision are intricate, and a conceptual framework to comprehend these potential determinants is currently lacking. To bridge this gap, this article proposed a conceptual framework that was developed through insights from the fields of both public management and health services, adjustment of PRISM model and elements, reference to the blocks of health system and reference to the framework of outcome indicators in implementation research. This conceptual framework included 4 modules which can be coherently and logically deduced, offered a multi-perspective understanding of the determinants to TB care, and hypothesized that the TB control services provided by the integrated TB control model is a public service and must be "patient-centered"; determinants of the integrated TB control model implementation can be divided into seven domains; the evaluation of the integrated TB control model implementation covers implementation outcomes and service outcomes. This framework offers the potential to guide empirical investigations, aiding in the understanding and identification of determinants, including barriers and facilitators, associated with the implementation of the integrated TB control health model. Furthermore, it serves as a valuable tool for developing interventions that address system-level barriers, drawing insights from the realms of public management and health services.
Collapse
Affiliation(s)
- Xi Chen
- Department of Social Medicine and Health Service Management, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, China
- Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiani Zhou
- Department of Social Medicine and Health Service Management, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, China
| | - Quan Yuan
- Department of Social Medicine and Health Service Management, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chunji Huang
- Army Medical University (Third Military Medical University), Chongqing, China
| | - Ying Li
- Department of Social Medicine and Health Service Management, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, China
| |
Collapse
|
2
|
Tadesse AW, Mganga A, Dube TN, Alacapa J, van Kalmthout K, Letta T, Mleoh L, Garfin AMC, Maraba N, Charalambous S, Foster N, Jerene D, Fielding KL. Feasibility and acceptability of the smart pillbox and medication label with differentiated care to support person-centered tuberculosis care among ASCENT trial participants - A multicountry study. Front Public Health 2024; 12:1327971. [PMID: 38444445 PMCID: PMC10913790 DOI: 10.3389/fpubh.2024.1327971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/15/2024] [Indexed: 03/07/2024] Open
Abstract
Introduction Digital adherence technologies (DATs) can offer alternative approaches to support tuberculosis treatment medication adherence. Evidence on their feasibility and acceptability in high TB burden settings is limited. We conducted a cross-sectional survey among adults with drug-sensitive tuberculosis (DS-TB), participating in pragmatic cluster-randomized trials for the Adherence Support Coalition to End TB project in Ethiopia (PACTR202008776694999), the Philippines, South Africa and Tanzania (ISRCTN 17706019). Methods From each country we selected 10 health facilities implementing the DAT intervention (smart pillbox or medication labels, with differentiated care support), ensuring inclusion of urban/rural and public/private facilities. Adults on DS-TB regimen using a DAT were randomly selected from each facility. Feasibility of the DATs was assessed using a standardized tool. Acceptability was measured using a 5-point Likert-scale, using the Capability, Opportunity, Motivation, Behavior (COM-B) model. Mean scores of Likert-scale responses within each COM-B category were estimated, adjusted for facility-level clustering. Data were summarized by country and DAT type. Results Participants using either the pillbox (n = 210) or labels (n = 169) were surveyed. Among pillbox users, phone ownership (79%), use of pillbox reminders (87%) and taking treatment without the pillbox (22%) varied by country. Among label users, phone ownership (81%), paying extra to use the labels (8%) and taking treatment without using labels (41%) varied by country. Poor network, problems with phone charging and access, not having the pillbox and forgetting to send text were reasons for not using DATs. Overall, people with TB had a favorable impression of both DATs, with mean composite scores between 4·21 to 4·42 across COM-B categories. Some disclosure concerns were reported. Conclusion From client-perspective, pillboxes and medication labels with differentiated care support were feasible to implement and acceptable in variety of settings. However, implementation challenges related to network, phone access, stigma, additional costs to people with TB to use DATs need to be addressed.
Collapse
Affiliation(s)
- Amare W. Tadesse
- TB Centre, Department of Infectious Disease Epidemiology and International Health, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | | | - Tanyaradzwa N. Dube
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | | | | | - Taye Letta
- National Tuberculosis Control Program, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
| | - Liberate Mleoh
- National Tuberculosis Control Program, Ministry of Health, Dodoma, Tanzania
| | - Anna M. C. Garfin
- National Tuberculosis Control Program, Department of Health, Manila, Philippines
| | - Noriah Maraba
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | - Salome Charalambous
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Nicola Foster
- TB Centre, Department of Infectious Disease Epidemiology and International Health, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | - Degu Jerene
- Evidence and Impact, KNCV Tuberculosis Plus, The Hague, Netherlands
| | - Katherine L. Fielding
- TB Centre, Department of Infectious Disease Epidemiology and International Health, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
3
|
Asmare L, Bayou FD, Arefaynie M, Mekonen AM, Tareke AA, Keleb A, Abera KM, Kebede N, Gebeyehu EM, Ayres A, Tsega Y, Endawkie A, Kebede SD, Abeje ET, Enyew EB, Daba C. Proportional Hazards Model on Attrition and its Predictors in Community Antiretroviral Refill Groups among ART Users in Eastern Ethiopia. J Int Assoc Provid AIDS Care 2024; 23:23259582241273338. [PMID: 39165103 PMCID: PMC11339742 DOI: 10.1177/23259582241273338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 06/23/2024] [Accepted: 07/12/2024] [Indexed: 08/22/2024] Open
Abstract
BACKGROUND The HIV epidemic continues to be a major public health challenge worldwide, particularly in sub-Saharan African countries such as Ethiopia. Community-based antiretroviral refill groups are emerging as a patient-centered approach, but there is limited evidence. Therefore, this study aimed to assess attrition and predictors in community antiretroviral refill groups among ART users in Eastern Ethiopia. METHODS Institutional-based retrospective cohort study was conducted. Systematic random sampling techniques were used. Data were collected via Kobo Collect and exported to Stata. Statistically significant effects were assumed for a P-value < 0.05 at a confidence interval of 95%. RESULTS The incidence of attrition in community-based ART refill groups was 6.63 (95% CI: 5.78, 7.48) per 100 person-years. The median duration of months in CAGs from the start till the end of the follow-up period was 9 months (IQR = 24). Thus, recruitment level from health facilities, history of LTFU, and stage IV were statistically significant variables. CONCLUSION The findings of this study highlight the importance of improving the use of community antiretroviral groups in care. Healthcare programs can ultimately improve health outcomes for individuals living with HIV.
Collapse
Affiliation(s)
- Lakew Asmare
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Fekade Demeke Bayou
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Mastewal Arefaynie
- Department of Reproductive and Family Health, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Asnakew Molla Mekonen
- Department of Health System and Management, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Abiyu Abadi Tareke
- Amref health in Africa, COVID-219 vaccine/EPI Technical Assistant at West Gondar Zonal Health Department, Gondar, Ethiopia
| | - Awoke Keleb
- Department of Environmental Health College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Kaleab Mesfin Abera
- Department of Health System and Management, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Natnael Kebede
- Department of Health Promotion, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Endalkachew Mesfin Gebeyehu
- Department of Health System and Management, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Aznamariam Ayres
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Yawkal Tsega
- Department of Health System and Management, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Abel Endawkie
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Shimels Derso Kebede
- Department of Health Informatics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Eyob Tilahun Abeje
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Ermias Bekele Enyew
- Department of Health Informatics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Chala Daba
- Department of Environmental Health College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| |
Collapse
|
4
|
Lee S, Rajaguru V, Baek JS, Shin J, Park Y. Digital Health Interventions to Enhance Tuberculosis Treatment Adherence: Scoping Review. JMIR Mhealth Uhealth 2023; 11:e49741. [PMID: 38054471 PMCID: PMC10718480 DOI: 10.2196/49741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/05/2023] [Accepted: 10/27/2023] [Indexed: 12/07/2023] Open
Abstract
Background Digital health technologies are widely used for disease management, with their computing platforms, software, and sensors being used for health care. These technologies are developed to manage chronic diseases and infectious bacterial diseases, including tuberculosis (TB). Objective This study aims to comprehensively review the literature on the use of digital health interventions (DHIs) for enhancing TB treatment adherence and identify major strategies for their adoption. Methods We conducted a literature search in the PubMed, Cochrane Library, Ovid Embase, and Scopus databases for relevant studies published between January 2012 and March 2022. Studies that focused on web-based or mobile phone-based interventions, medication adherence, digital health, randomized controlled trials, digital interventions, or mobile health and ubiquitous health technology for TB treatment and related health outcomes were included. Results We identified 27 relevant studies and classified them according to the intervention method, a significant difference in treatment success, and health outcomes. The following interventions were emphasized: SMS text messaging interventions (8/27, 30%), medicine reminders (6/27, 22%), and web-based direct observation therapy (9/27, 33%). Digital health technology significantly promoted disease management among individuals and health care professionals. However, only a few studies addressed 2-way communication therapies, such as interactive SMS text messaging and feedback systems. Conclusions This scoping review classified studies on DHIs for patients with TB and demonstrated their potential for the self-management of TB. DHIs are still being developed, and evidence on the impact of digital technologies on enhancing TB treatment adherence remains limited. However, it is necessary to encourage patients' participation in TB treatment and self-management through bidirectional communication. We emphasize the importance of developing a communication system.
Collapse
Affiliation(s)
- Sol Lee
- Yonsei University Health System, Yonsei University, Seoul, Republic of Korea
| | - Vasuki Rajaguru
- Department of Healthcare Management, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
| | - Joon Sang Baek
- Department of Human Environment & Design, Yonsei University, Seoul, Republic of Korea
| | - Jaeyong Shin
- Department of Preventive Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
- Institute for Innovation in Digital Healthcare, Yonsei University, Seoul, Republic of Korea
| | - Youngmok Park
- Institute for Innovation in Digital Healthcare, Yonsei University, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Tadesse AW, Cusinato M, Weldemichael GT, Abdurhman T, Assefa D, Yazew H, Gadissa D, Shiferaw A, Belachew M, Sahile M, van Rest J, Bedru A, Foster N, Jerene D, Fielding KL. Risk factors for poor engagement with a smart pillbox adherence intervention among persons on tuberculosis treatment in Ethiopia. BMC Public Health 2023; 23:2006. [PMID: 37838677 PMCID: PMC10576388 DOI: 10.1186/s12889-023-16905-z] [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: 05/17/2023] [Accepted: 10/05/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Non-adherence to tuberculosis treatment increases the risk of poor treatment outcomes. Digital adherence technologies (DATs), including the smart pillbox (EvriMED), aim to improve treatment adherence and are being widely evaluated. As part of the Adherence Support Coalition to End TB (ASCENT) project we analysed data from a cluster-randomised trial of DATs and differentiated care in Ethiopia to examine individual-factors for poor engagement with the smart pillbox. METHODS Data were obtained from a cohort of trial participants with drug-sensitive tuberculosis (DS-TB) whose treatment started between 1 December 2020 and 1 May 2022, and who were using the smart pillbox. Poor engagement with the pillbox was defined as (i) > 20% days with no digital confirmation and (ii) the count of days with no digital confirmation, and calculated over a two evaluation periods (56-days and 168-days). Logistic random effects regression was used to model > 20% days with no digital confirmation and negative binomial random effects regression to model counts of days with no digital confirmation, both accounting for clustering of individuals at the facility-level. RESULTS Among 1262 participants, 10.8% (133/1262) over 56-days and 15.8% (200/1262) over 168-days had > 20% days with no digital confirmation. The odds of poor engagement was less among participants in the higher stratum of socio-economic position (SEP) over 56-days. Overall, 4,689/67,315 expected doses over 56-days and 18,042/199,133 expected doses over 168-days were not digitally confirmed. Compared to participants in the poorest SEP stratum, participants in the wealthiest stratum had lower rates of days not digitally confirmed over 168-days (adjusted rate ratio [RRa]:0.79; 95% confidence interval [CI]: 0.65, 0.96). In both evaluation periods (56-days and 168-days), HIV-positive status (RRa:1.29; 95%CI: 1.02, 1.63 and RRa:1.28; 95%CI: 1.07, 1.53), single/living independent (RRa:1.31; 95%CI: 1.03, 1.67 and RRa:1.38; 95%CI: 1.16, 1.64) and separated/widowed (RRa:1.40; 95%CI: 1.04, 1.90 and RRa:1.26; 95%CI: 1.00, 1.58) had higher rates of counts of days with no digital confirmation. CONCLUSION Poorest SEP stratum, HIV-positive status, single/living independent and separated/ widowed were associated with poor engagement with smart pillbox among people with DS-TB in Ethiopia. Differentiated care for these sub-groups may reduce risk of non-adherence to TB treatment.
Collapse
Affiliation(s)
- Amare Worku Tadesse
- TB Centre, Department of Infectious Disease Epidemiology, London, School of Hygiene & Tropical Medicine (LSHTM) , London, UK.
| | - Martina Cusinato
- TB Centre, Department of Infectious Disease Epidemiology, London, School of Hygiene & Tropical Medicine (LSHTM) , London, UK
- Bristol Medical School, Population Health Sciences, Bristol, UK
| | | | | | | | | | | | | | | | | | | | | | - Nicola Foster
- TB Centre, Department of Infectious Disease Epidemiology, London, School of Hygiene & Tropical Medicine (LSHTM) , London, UK
| | - Degu Jerene
- KNCV Tuberculosis Plus, The Hague, Netherlands
| | - Katherine Linda Fielding
- TB Centre, Department of Infectious Disease Epidemiology, London, School of Hygiene & Tropical Medicine (LSHTM) , London, UK
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
7
|
Foster N, Tadesse AW, McQuaid CF, Gosce L, Abdurhman T, Assefa D, Bedru A, Houben RMGJ, van Kalmthout K, Letta T, Mohammed Z, van Rest J, Umeta DG, Weldemichael GT, Yazew H, Jerene D, Quaife M, Fielding KL. Evaluating the equity impact and cost-effectiveness of digital adherence technologies with differentiated care to support tuberculosis treatment adherence in Ethiopia: protocol and analysis plan for the health economics component of a cluster randomised trial. Trials 2023; 24:292. [PMID: 37095533 PMCID: PMC10123464 DOI: 10.1186/s13063-023-07289-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: 01/25/2023] [Accepted: 04/03/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Tuberculosis remains a leading infectious cause of death in resource-limited settings. Effective treatment is the cornerstone of tuberculosis control, reducing mortality, recurrence and transmission. Supporting treatment adherence through facility-based observations of medication taking can be costly to providers and patients. Digital adherence technologies (DATs) may facilitate treatment monitoring and differentiated care. The ASCENT-Ethiopia study is a three-arm cluster randomised trial assessing two DATs with differentiated care for supporting tuberculosis treatment adherence in Ethiopia. This study is part of the ASCENT consortium, assessing DATs in South Africa, the Philippines, Ukraine, Tanzania and Ethiopia. The aim of this study is to determine the costs, cost-effectiveness and equity impact of implementing DATs in Ethiopia. METHODS AND DESIGN A total of 78 health facilities have been randomised (1:1:1) into one of two intervention arms or a standard-of-care arm. Approximately 50 participants from each health facility will be enrolled on the trial. Participants in facilities randomised to the intervention arms are offered a DAT linked to the ASCENT adherence platform for daily adherence monitoring and differentiated response for those who have missed doses. Participants at standard-of-care facilities receive routine care. Treatment outcomes and resource utilisation will be measured for each participant. The primary effectiveness outcome is a composite index of unfavourable end-of-treatment outcomes (lost to follow-up, death or treatment failure) or treatment recurrence within 6 months of end-of-treatment. For the cost-effectiveness analysis, end-of-treatment outcomes will be used to estimate disability-adjusted life years (DALYs) averted. Provider and patient cost data will be collected from a subsample of 5 health facilities per study arm, 10 participants per facility (n = 150). We will conduct a societal cost-effectiveness analysis using Bayesian hierarchical models that account for the individual-level correlation between costs and outcomes as well as intra-cluster correlation. An equity impact analysis will be conducted to summarise equity efficiency trade-offs. DISCUSSION Trial enrolment is ongoing. This paper follows the published trial protocol and describes the protocol and analysis plan for the health economics work package of the ASCENT-Ethiopia trial. This analysis will generate economic evidence to inform the implementation of DATs in Ethiopia and globally. TRIAL REGISTRATION Pan African Clinical Trial Registry (PACTR) PACTR202008776694999. Registered on 11 August 2020, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12241 .
Collapse
Affiliation(s)
- Nicola Foster
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Amare W Tadesse
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Christopher Finn McQuaid
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Lara Gosce
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Ahmed Bedru
- KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Rein M G J Houben
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Taye Letta
- National Tuberculosis Control Program, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
| | | | - Job van Rest
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | | | | | - Hiwot Yazew
- KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Degu Jerene
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - Matthew Quaife
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Katherine L Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
8
|
Jerene D, Levy J, van Kalmthout K, Rest JV, McQuaid CF, Quaife M, Charalambous S, Gamazina K, Garfin AMC, Mleoh L, Terleieva Y, Bogdanov A, Maraba N, Fielding K. Effectiveness of digital adherence technologies in improving tuberculosis treatment outcomes in four countries: a pragmatic cluster randomised trial protocol. BMJ Open 2023; 13:e068685. [PMID: 36918242 PMCID: PMC10016242 DOI: 10.1136/bmjopen-2022-068685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 03/02/2023] [Indexed: 03/16/2023] Open
Abstract
INTRODUCTION Successful treatment of tuberculosis depends to a large extent on good adherence to treatment regimens, which relies on directly observed treatment (DOT). This in turn requires frequent visits to health facilities. High costs to patients, stigma and burden to the health system challenged the DOT approach. Digital adherence technologies (DATs) have emerged as possibly more feasible alternatives to DOT but there is conflicting evidence on their effectiveness and feasibility. Our primary objective is to evaluate whether the implementation of DATs with daily monitoring and a differentiated response to patient adherence would reduce poor treatment outcomes compared with the standard of care (SOC). Our secondary objectives include: to evaluate the proportion of patients lost to follow-up; to compare effectiveness by DAT type; to evaluate the feasibility and acceptability of DATs; to describe factors affecting the longitudinal engagement of patients with the intervention and to use a simple model to estimate the epidemiological impact and cost-effectiveness of the intervention from a health system perspective. METHODS AND ANALYSIS This is a pragmatic two-arm cluster-randomised trial in the Philippines, South Africa, Tanzania and Ukraine, with health facilities as the unit of randomisation. Facilities will first be randomised to either the DAT or SOC arm, and then the DAT arm will be further randomised into medication sleeve/labels or smart pill box in a 1:1:2 ratio for the smart pill box, medication sleeve/label or the SOC respectively. We will use data from the digital adherence platform and routine health facility records for analysis. In the main analysis, we will employ an intention-to-treat approach to evaluate treatment outcomes. ETHICS AND DISSEMINATION The study has been approved by the WHO Research Ethics Review Committee (0003296), and by country-specific committees. The results will be shared at national and international meetings and will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN17706019.
Collapse
Affiliation(s)
- Degu Jerene
- Division of Tuberculosis Elimination and Health Systems Strengthening, KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Jens Levy
- Division of Tuberculosis Elimination and Health Systems Strengthening, KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Kristian van Kalmthout
- Division of Tuberculosis Elimination and Health Systems Strengthening, KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Job van Rest
- Division of Tuberculosis Elimination and Health Systems Strengthening, KNCV Tuberculosis Foundation, The Hague, Netherlands
| | - Christopher Finn McQuaid
- TB Centre and Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew Quaife
- TB Centre and Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Katya Gamazina
- Program for Appropriate Technology in Health, Kyiv, Ukraine
| | - A M Celina Garfin
- Department of Health, Infectious Diseases Prevention and Control Division, Disease Prevention and Control Bureau, Manila, the Philippines
| | - Liberate Mleoh
- Department of Preventive Services, National Tuberculosis and Leprosy Programme, Dodoma, United Republic of Tanzania
| | - Yana Terleieva
- Department of Coordination of TB Treatment Programs, Kyiv, Ukraine
| | | | | | - Katherine Fielding
- TB Centre and Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
9
|
Subbaraman R, Haberer JE, Fielding K. Intention to Treat or per Protocol? Overly Optimistic Findings Regarding the Cost-Effectiveness of 99DOTS, a Tuberculosis Digital Adherence Technology. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022:S1098-3015(22)02187-8. [PMID: 36266217 DOI: 10.1016/j.jval.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/12/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA; Center for Global Public Health, Tufts University School of Medicine, Boston, MA, USA; Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, MA, USA.
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Katherine Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, England, UK
| |
Collapse
|