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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.
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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
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Wang X, Fu Q, Zhou M, Li Y. How Integrated Digital Tools Can Improve Tuberculosis Medication Adherence: A Longitudinal Study in China. Telemed J E Health 2024; 30:490-498. [PMID: 37498525 DOI: 10.1089/tmj.2023.0084] [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] [Indexed: 07/28/2023] Open
Abstract
Background: Poor medication adherence remains one of the major problems in the treatment of tuberculosis (TB) patients, while digital technologies have been proven effective to improve the treatment results. However, reports on the effectiveness of comprehensive practice integrating different intervention methods and technologies are limited. The aim of this study is to evaluate the effectiveness of an integrated digital adherence intervention for TB patients. Methods: We developed a digital adherence intervention platform integrating instant WeChat message, electronic medication monitors (EMMs), and manual reminders. The primary goal of the platform was to improve the accessibility of digital adherence technologies, and thus improve treatment adherence. TB patients were newly diagnosed at 10 TB-designated hospitals and came from 220 communities, from January to June 2022. The basic characteristics and treatment adherence of TB patients in WeChat, EMM, and conventional groups were compared, and the influencing factors of high medication adherence were analyzed by logistic regression. Results: A total of 2,498 TB patients were enrolled in the study, 14.5% were managed by digital technologies, 9.5% by WeChat, and 5.0% by EMM, respectively. After intervention, the median medication rate of TB patients was significantly higher in the WeChat group (95.3%) and EMM group (95.7%) compared with that of the conventional group (83.8%). On the contrary, the median number of missed medications among patients of the conventional group (nine times) was significantly higher than that in the WeChat (three times) group and EMM (three times) group. The proportion of high adherence (adherence medication rate ≥90%) among TB patients was 64.7%, 64.5%, and 43.2% in WeChat, EMM, and conventional group, respectively. Conclusions: The application of the integrated digital adherence intervention platform could significantly improve medication adherence among TB patients. The accessibility of digital adherence technologies could be improved by integrating complementary technologies in practice.
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Affiliation(s)
- Xiaojun Wang
- Wuhan Institute for Tuberculosis Control, Wuhan Pulmonary Hospital, Wuhan, China
| | - Qian Fu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meilan Zhou
- Wuhan Institute for Tuberculosis Control, Wuhan Pulmonary Hospital, Wuhan, China
| | - Yuehua Li
- Wuhan Institute for Tuberculosis Control, Wuhan Pulmonary Hospital, Wuhan, China
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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.
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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
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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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Rodrigues R, Varghese SS, Mahrous M, Ananthaneni Kumar A, Ahmed MN, D'Souza G. Feasibility and acceptability pilot of video-based direct observed treatment (vDOT) for supporting antitubercular treatment in South India: a cohort study. BMJ Open 2023; 13:e065878. [PMID: 37247959 DOI: 10.1136/bmjopen-2022-065878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVES The objective of this study was to assess the feasibility and acceptability of video-based anti-tuberculosis (TB) treatment adherence support in patients with TB (PwTB) in South India. DESIGN An exploratory cohort. SETTING Participants were recruited at the TB treatment centre (direct observed treatment short centre) of a tertiary-level teaching facility in Bangalore, Karnataka, South India. PARTICIPANTS The study enrolled 25 PwTB, with replacement. Adult PwTB who were on drug-sensitive treatment regimens were included, while those who had drug resistant TB were excluded from the study. INTERVENTION Participants received scheduled adherence reminders and were trained to videorecord themselves swallowing their medication via a mobile application. The application was automated to submit these videos for evaluation. Participants were followed up monthly till treatment completion or withdrawal. OUTCOME MEASURES Adherence rate and acceptability of video-based directly observed treatment (vDOT). RESULTS The mean±SD age of the participants was 33±14 years, majority were females (16, 64%), residing in urban areas (24,96%), married (17, 68%) and had access to smart phones (23,92%). A total of 3193 person days of follow-up was completed; of the videos submitted within the first 6 months of enrollment (2501), 94% (2354/2501) were considered 'acceptable' and 16 (64%) participants were optimally adherent (ie, ≥80%). Participant videos improved in quality and a higher proportion met acceptability criteria over time. Twenty-one (84%) participants stated that they found the application easy to learn; 13 (52%) preferred vDOT over DOT. Mixed model logistic regression showed that those who are married are more likely have daily adherence to anti-TB treatment. CONCLUSION Video-based mobile phone interventions are acceptable to PwTB and the ease of using the application increases with time. To provide patient-centred care, vDOT is a promising option that can be offered to patients for treatment support and adherence monitoring.
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Affiliation(s)
- Rashmi Rodrigues
- Community Health, St John's National Academy of Health Sciences, Bangalore, Karnataka, India
- Global Public Health, Karolinska Institute, Stockholm, Sweden
- Intermidiate Fellow, Clinical and Public Health, DBT/ Wellcome Trust India Alliance, Hyderabad, India
| | - Suman Sarah Varghese
- St. John's Research Institute, St John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | | | - Anil Ananthaneni Kumar
- St. John's Research Institute, St John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Mohammed Naseer Ahmed
- St. John's Research Institute, St John's National Academy of Health Sciences, Bangalore, Karnataka, India
- Blackpool Teaching Hospital, NHS trust, Blackpool, UK
| | - George D'Souza
- Pulmonary Medicine, St John's National Academy of Health Sciences, Bangalore, Karnataka, India
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Teo AKJ, Rahevar K, Morishita F, Ang A, Yoshiyama T, Ohkado A, Kawatsu L, Yamada N, Uchimura K, Choi Y, Chen Z, Yi S, Yanagawa M, Oh KH, Viney K, Marais B, Kim H, Kato S, Liu Y, Ong CW, Islam T. Tuberculosis in older adults: case studies from four countries with rapidly ageing populations in the western pacific region. BMC Public Health 2023; 23:370. [PMID: 36810018 PMCID: PMC9942033 DOI: 10.1186/s12889-023-15197-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 02/02/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND The Western Pacific Region has one of the fastest-growing populations of older adults (≥ 65 years) globally, among whom tuberculosis (TB) poses a particular concern. This study reports country case studies from China, Japan, the Republic of Korea, and Singapore reflecting on their experiences in managing TB among older adults. FINDINGS Across all four countries, TB case notification and incidence rates were highest among older adults, but clinical and public health guidance focused on this population was limited. Individual country reports illustrated a range of practices and challenges. Passive case finding remains the norm, with limited active case finding (ACF) programs implemented in China, Japan, and the Republic of Korea. Different approaches have been trialled to assist older adults in securing an early diagnosis, as well as adhering to their TB treatment. All countries emphasised the need for person-centred approaches that include the creative application of new technology and tailored incentive programs, as well as reconceptualisation of how we provide treatment support. The use of traditional medicines was found to be culturally entrenched among older adults, with a need for careful consideration of their complementary use. TB infection testing and the provision of TB preventive treatment (TPT) were underutilised with highly variable practice. CONCLUSION Older adults require specific consideration in TB response policies, given the burgeoning aging population and their high TB risk. Policymakers, TB programs and funders must invest in and develop locally contextualised practice guidelines to inform evidence-based TB prevention and care practices for older adults.
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Affiliation(s)
- Alvin Kuo Jing Teo
- grid.4280.e0000 0001 2180 6431Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore ,grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, University of Sydney, Sydney, NSW Australia ,grid.1013.30000 0004 1936 834XThe University of Sydney Institute for Infectious Diseases (Sydney ID) and the Centre of Research Excellence in Tuberculosis (TB-CRE), Sydney, NSW Australia
| | - Kalpeshsinh Rahevar
- World Health Organization, Regional Office for the Western Pacific, Manila, Philippines.
| | - Fukushi Morishita
- grid.483407.c0000 0001 1088 4864World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Alicia Ang
- grid.508010.cDivision of Infectious Diseases, Department of Medicine, Woodlands Health, Singapore, Singapore
| | - Takashi Yoshiyama
- grid.419151.90000 0001 1545 6914Research Institute of Tuberculosis, Anti-Tuberculosis Association, Tokyo, Japan
| | - Akihiro Ohkado
- grid.419151.90000 0001 1545 6914Research Institute of Tuberculosis, Anti-Tuberculosis Association, Tokyo, Japan
| | - Lisa Kawatsu
- grid.419151.90000 0001 1545 6914Research Institute of Tuberculosis, Anti-Tuberculosis Association, Tokyo, Japan
| | - Norio Yamada
- grid.419151.90000 0001 1545 6914Research Institute of Tuberculosis, Anti-Tuberculosis Association, Tokyo, Japan
| | - Kazuhiro Uchimura
- grid.419151.90000 0001 1545 6914Research Institute of Tuberculosis, Anti-Tuberculosis Association, Tokyo, Japan
| | - Youngeun Choi
- Korean National Tuberculosis Association, Seoul, Republic of Korea
| | - Zi Chen
- Office of International Cooperation, Innovation Alliance on Tuberculosis Diagnosis and Treatment, Beijing, China
| | - Siyan Yi
- grid.4280.e0000 0001 2180 6431Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore ,grid.513124.00000 0005 0265 4996KHANA Center for Population Health Research, Phnom Penh, Cambodia ,grid.265117.60000 0004 0623 6962Center for Global Health Research, Public Health Program, Touro University California, Vallejo, CA USA
| | - Manami Yanagawa
- grid.483407.c0000 0001 1088 4864World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Kyung Hyun Oh
- grid.483407.c0000 0001 1088 4864World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Kerri Viney
- grid.3575.40000000121633745Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Ben Marais
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, University of Sydney, Sydney, NSW Australia ,grid.1013.30000 0004 1936 834XThe University of Sydney Institute for Infectious Diseases (Sydney ID) and the Centre of Research Excellence in Tuberculosis (TB-CRE), Sydney, NSW Australia
| | - Heejin Kim
- Korean National Tuberculosis Association, Seoul, Republic of Korea
| | - Seiya Kato
- grid.419151.90000 0001 1545 6914Research Institute of Tuberculosis, Anti-Tuberculosis Association, Tokyo, Japan
| | - Yuhong Liu
- grid.24696.3f0000 0004 0369 153XBeijing Chest Hospital, Capital Medical University, Beijing, China
| | - Catherine W.M. Ong
- grid.412106.00000 0004 0621 9599Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore, Singapore ,grid.4280.e0000 0001 2180 6431Infectious Diseases Translational Research Programme, Department of Medicine, National University of Singapore, Singapore, Singapore ,grid.4280.e0000 0001 2180 6431Institute of Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
| | - Tauhid Islam
- grid.483407.c0000 0001 1088 4864World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
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Manyazewal T, Woldeamanuel Y, Getinet T, Hoover A, Bobosha K, Fuad O, Getahun B, Fekadu A, Holland DP, Marconi VC. Patient-reported usability and satisfaction with electronic medication event reminder and monitor device for tuberculosis: a multicentre, randomised controlled trial. EClinicalMedicine 2023; 56:101820. [PMID: 36684395 PMCID: PMC9853306 DOI: 10.1016/j.eclinm.2022.101820] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 01/18/2023] Open
Abstract
Background The success of a tuberculosis digital adherence technology relies on patients' satisfaction with and the usability of the technology. This study aimed to evaluate treatment satisfaction and usability of a digital medication event reminder and monitor (MERM) device for patients with tuberculosis to address the prespecified secondary endpoint of the SELFTB trial. Methods In this multicenter, randomised controlled trial, adults (≥18 years) with new or previously treated, bacteriologically-confirmed, drug-sensitive pulmonary tuberculosis who were eligible to start anti-tuberculosis therapy were recruited from 10 healthcare facilities in Ethiopia. With a computer-generated random number sequence, participants were randomly assigned 1:1 to receive a 15-day tuberculosis medication supply dispensed with an evriMED500® MERM device to self-administer and return every 15 days or the standard in-person DOT. Both arms were followed throughout the standard two-month intensive treatment phase. Treatment was based on the WHO-recommended two-month fixed-dose-combination of first-line anti-tuberculosis drug delivered as a single daily dose (2RHZE). Treatment Satisfaction Questionnaire for Medication version 4 (TSQM 1.4©) was used to measure and compare treatment satisfaction between arms. Adapted System Usability Scale (SUS) was used to assess the usability of the device, with emphasis on ease of use, challenges, benefits, motivation, popularity, and recommendation. The findings were correlated with adherence and clinical endpoints including sputum smear conversion and IsoScreen urine isoniazid test results. This trial is registered with ClinicalTrials.gov, NCT04216420. Findings Between June 2, 2020, and June 15, 2021, 337 patients were screened for eligibility, of whom 109 participants enrolled and completed the satisfaction [control (n = 57) and intervention (n = 52) arms] and usability [intervention arm (n = 52)] questionnaires. TSQM 1.4© geometric mean scores were: Effectiveness 73.25 [geometric standard deviation (GSD) 1.28], Side Effects 100, Convenience 63.31 (GSD 1.45), and Global Satisfaction 77.29 (GSD 1.25). TSQM score was significantly higher in the intervention vs the control: Effectiveness [85.78 vs 63.43, 95% CI 1.35 (1.26-1.45), p < 0.001], Convenience [85.41 vs 48.18, 95% CI 1.77 (1.63-1.93), p < 0.001], and Global Satisfaction [90.19 vs 67.11, 95% CI 1.34 (1.26-1.43), p < 0.001]. There were significant associations between Global Satisfaction and medication adherence (p = 0.017). Average SUS score was 97.45%, which was close to the best imaginable SUS value of 100%. Likelihood to Recommend (LTR) value was ≥9, on a scale of 0-10, for 90.4% of MERM users, yielding higher net promoters. There was no significant association between usability and medication adherence (p = 0.691). Interpretation Our findings suggested that treatment satisfaction scores were superior in the intervention vs control arms and across the domains of Effectiveness, Convenience, and Global Satisfaction. There was excellent usability of the MERM device and a significantly higher number of users likely to promote the device. High tuberculosis burden countries may transform patient-centered care through ongoing evaluation and scale-up of digital health innovations. Funding U.S. National Institute of Health (NIH) Fogarty International Center and National Institute of Allergy and Infectious Diseases (D43 TW009127) and the Emory Center for AIDS Research (P30 AI050409).
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Affiliation(s)
- Tsegahun Manyazewal
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia
| | - Yimtubezinash Woldeamanuel
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia
| | - Tewodros Getinet
- St. Paul's Hospital Millennium Medical College, School of Public Health, Addis Ababa, Ethiopia
| | - Alison Hoover
- Emory University School of Medicine, Division of Infectious Diseases, Global Health Programs, Atlanta, 30322, Georgia, USA
| | - Kidist Bobosha
- Armauer Hansen Research Institute (AHRI), Addis Ababa, Ethiopia
| | - Oumer Fuad
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia
| | | | - Abebaw Fekadu
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa, Ethiopia
| | - David P. Holland
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, 30322, Georgia, USA
| | - Vincent C. Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, 30322, Georgia, USA
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Manyazewal T, Woldeamanuel Y, Holland DP, Fekadu A, Marconi VC. Effectiveness of a digital medication event reminder and monitor device for patients with tuberculosis (SELFTB): a multicenter randomized controlled trial. BMC Med 2022; 20:310. [PMID: 36167528 PMCID: PMC9514884 DOI: 10.1186/s12916-022-02521-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 08/09/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Tuberculosis remains the leading cause of death from a single infectious disease worldwide. Trials evaluating digital adherence technologies for tuberculosis in low- and middle-income countries are urgently needed. We aimed to assess whether a digital medication event reminder and monitor (MERM) device-observed self-administered therapy improves adherence and treatment outcomes in patients with tuberculosis compared with the standard in-person directly observed therapy (DOT). METHODS We did a two-arm, attention-controlled, effectiveness-implementation type 2 hybrid, randomized controlled trial in ten healthcare facilities in Addis Ababa, Ethiopia. We included adults with new or previously treated, bacteriologically confirmed, drug-sensitive pulmonary tuberculosis who were eligible to start anti-tuberculosis therapy. Participants were randomly assigned (1:1) to receive a 15-day tuberculosis medication supply in the evriMED500® MERM device to self-administer and return every 15 days (intervention arm) or visit the healthcare facilities each day to swallow their daily dose with DOT by healthcare providers (control arm). Both arms were followed throughout the standard two-month intensive treatment phase (2RHZE). For control participants, some provider-approved take-home doses might be allowed for extenuating circumstances in real-world practice. Data were collected on patient information (demographic, socioeconomic, behavioral, social, and clinical information), medication adherence measures (MERM vs. DOT records, IsoScreenTM urine colorimetric isoniazid test, and adherence self-report), and clinical measures (pre-post treatment sputum Xpert MTB/RIF assay or microscopy, and adverse treatment outcomes). The intention-to-treat (ITT) primary endpoints were (1) individual-level percentage adherence over the two-month intensive phase measured by adherence records compiled from MERM device vs. DOT records that also considered all take-home doses as having been ingested and (2) sputum smear conversion following the standard two-month intensive phase treatment. Secondary endpoints were (1) individual-level percentage adherence over the two-month intensive phase measured by adherence records compiled from the MERM device vs. DOT records that considered all take-home doses as not ingested, (2) negative IsoScreen urine isoniazid test, (3) adverse treatment outcome (having at least one of the three events: treatment not completed; death; or loss to follow-up), and (4) self-reported adherence. The MERM device has an electronic module and a medication container that records adherence, stores medication, emits audible and visual on-board alarms to remind patients to take their medications on time and refill, and enables providers to download the data and monitor adherence. RESULTS Participants were enrolled into the study between 02 June 2020 and 15 June 2021, with the last participant completing follow-up on 15 August 2021. A total of 337 patients were screened for eligibility, of whom 114 were randomly assigned and included in the final analysis [57 control and 57 intervention participants]. Participants were 64.9% male, 15% with HIV, 10.5% retreatment, and 5.3% homeless. Adherence to TB medication was comparable between the intervention arm [geometric mean percentage (GM%) 99.01%, geometric standard deviation (GSD) 1.02] and the control arm [GM% 98.97%, GSD 1.04] and was within the prespecified margin for non-inferiority [mean ratio (MR) 1.00 (95% CI 0.99-1.01); p = 0.954]. The intervention arm was significantly superior to the control arm in the secondary analysis that considered all take-home doses in the control were not ingested [control GM% 77.71 (GSD 1.57), MR 1.27 (95% CI 1.33-1.43)]. Urine isoniazid testing was done on 443 (97%) samples from 114 participants; 13 participants had at least one negative result; a negative test was significantly more common among the control group compared with the intervention group [11/57 (19.3%) vs 2/57 (3.5%); p = 0.008]. There was no significant difference between the control and intervention arms for smear conversion [55 (98.2%) vs 52 (100%); p>0.999], adverse treatment outcomes [0 vs 1 (1.9%); p = 0.48], and self-report non-adherence [5 (8.9%) vs 1 (1.9%); p = 0.21]. CONCLUSIONS In this randomized trial of patients with drug-sensitive pulmonary tuberculosis, medication adherence among participants assigned to MERM-observed self-administered therapy was non-inferior and superior by some measures when compared with the standard in-person DOT. Further research is needed to understand whether adherence in the intervention is primarily driven by allowing self-administered therapy which reduced challenges of repeated clinic visits or by the adherence support provided by the MERM system. To avoid contributing to patient barriers with DOT, tuberculosis medical programs should consider alternatives such as medication event monitors. TRIAL REGISTRATION ClinicalTrials.gov, NCT04216420.
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Affiliation(s)
- Tsegahun Manyazewal
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), P.O. Box 9086, Addis Ababa, Ethiopia
| | - Yimtubezinash Woldeamanuel
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), P.O. Box 9086, Addis Ababa, Ethiopia
| | - David P. Holland
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia 30322 USA
| | - Abebaw Fekadu
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), P.O. Box 9086, Addis Ababa, Ethiopia
| | - Vincent C. Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia 30322 USA
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9
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Mason M, Cho Y, Rayo J, Gong Y, Harris M, Jiang Y. Technologies for Medication Adherence Monitoring and Technology Assessment Criteria: Narrative Review. JMIR Mhealth Uhealth 2022; 10:e35157. [PMID: 35266873 PMCID: PMC8949687 DOI: 10.2196/35157] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/23/2022] [Accepted: 01/28/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Accurate measurement and monitoring of patient medication adherence is a global challenge because of the absence of gold standard methods for adherence measurement. Recent attention has been directed toward the adoption of technologies for medication adherence monitoring, as they provide the opportunity for continuous tracking of individual medication adherence behavior. However, current medication adherence monitoring technologies vary according to their technical features and data capture methods, leading to differences in their respective advantages and limitations. Overall, appropriate criteria to guide the assessment of medication adherence monitoring technologies for optimal adoption and use are lacking. OBJECTIVE This study aims to provide a narrative review of current medication adherence monitoring technologies and propose a set of technology assessment criteria to support technology development and adoption. METHODS A literature search was conducted on PubMed, Scopus, CINAHL, and ProQuest Technology Collection (2010-present) using the combination of keywords medication adherence, measurement technology, and monitoring technology. The selection focused on studies related to medication adherence monitoring technology and its development and use. The technological features, data capture methods, and potential advantages and limitations of the identified technology applications were extracted. Methods for using data for adherence monitoring were also identified. Common recurring elements were synthesized as potential technology assessment criteria. RESULTS Of the 3865 articles retrieved, 98 (2.54%) were included in the final review, which reported a variety of technology applications for monitoring medication adherence, including electronic pill bottles or boxes, ingestible sensors, electronic medication management systems, blister pack technology, patient self-report technology, video-based technology, and motion sensor technology. Technical features varied by technology type, with common expectations for using these technologies to accurately monitor medication adherence and increase adoption in patients' daily lives owing to their unobtrusiveness and convenience of use. Most technologies were able to provide real-time monitoring of medication-taking behaviors but relied on proxy measures of medication adherence. Successful implementation of these technologies in clinical settings has rarely been reported. In all, 28 technology assessment criteria were identified and organized into the following five categories: development information, technology features, adherence to data collection and management, feasibility and implementation, and acceptability and usability. CONCLUSIONS This narrative review summarizes the technical features, data capture methods, and various advantages and limitations of medication adherence monitoring technology reported in the literature and the proposed criteria for assessing medication adherence monitoring technologies. This collection of assessment criteria can be a useful tool to guide the development and selection of relevant technologies, facilitating the optimal adoption and effective use of technology to improve medication adherence outcomes. Future studies are needed to further validate the medication adherence monitoring technology assessment criteria and construct an appropriate technology assessment framework.
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Affiliation(s)
- Madilyn Mason
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Youmin Cho
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Jessica Rayo
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Yang Gong
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Marcelline Harris
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Yun Jiang
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
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10
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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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11
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Subbaraman R, Thomas BE, Kumar JV, Lubeck-Schricker M, Khandewale A, Thies W, Eliasziw M, Mayer KH, Haberer JE. Measuring Tuberculosis Medication Adherence: A Comparison of Multiple Approaches in Relation to Urine Isoniazid Metabolite Testing Within a Cohort Study in India. Open Forum Infect Dis 2021; 8:ofab532. [PMID: 35559123 PMCID: PMC9088502 DOI: 10.1093/ofid/ofab532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/13/2021] [Indexed: 12/24/2022] Open
Abstract
Background Nonadherence to tuberculosis medications is associated with poor outcomes. However, measuring adherence in practice is challenging. In this study, we evaluated the accuracy of multiple tuberculosis adherence measures. Methods We enrolled adult Indians with drug-susceptible tuberculosis who were monitored using 99DOTS, a cellphone-based technology. During an unannounced home visit with each participant, we assessed adherence using a pill estimate, 4-day dose recall, a last missed dose question, and urine isoniazid metabolite testing. We estimated the area under the receiver operating characteristic curve (AUC) for each alternate measure in comparison to urine testing. 99DOTS data were analyzed using patient-reported doses alone and patient- and provider-reported doses, the latter reflecting how 99DOTS is implemented in practice. We assessed each measure's operating characteristics, with particular interest in specificity-that is, the percentage of participants detected as being nonadherent by each alternate measure, among those who were nonadherent by urine testing. Results Compared with urine testing, alternate measures had the following characteristics: 99DOTS patient-reported doses alone (area under the curve [AUC], 0.65; specificity, 70%; 95% CI, 58%-81%), 99DOTS patient- and provider-reported doses (AUC, 0.61; specificity, 33%; 95% CI, 22%-45%), pill estimate (AUC, 0.55; specificity, 21%; 95% CI, 12%-32%), 4-day recall (AUC, 0.60; specificity, 23%; 95% CI, 14%-34%), and last missed dose question (AUC, 0.65; specificity, 52%; 95% CI, 40%-63%). Conclusions Alternate measures missed detecting at least 30% of people who were nonadherent by urine testing. The last missed dose question performed similarly to 99DOTS using patient-reported doses alone. Tuberculosis programs should evaluate the feasibility of integrating more accurate, objective measures, such as urine testing, into routine care.
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Affiliation(s)
- Ramnath Subbaraman
- Department of Public Health and Community Medicine and 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
| | - Beena E Thomas
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India,Correspondence: Beena E. Thomas, PhD, MSW, Department of Social and Behavioural Research, ICMR- National Institute for Research in Tuberculosis, No. 1, Mayor Sathiyamoorthy Road, Chetpet, Chennai-600 031, India ()
| | - J Vignesh Kumar
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Maya Lubeck-Schricker
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Amit Khandewale
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - William Thies
- Microsoft Research India, Bangalore, Karnataka, India
| | - Misha Eliasziw
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Health and Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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12
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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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13
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Wang N, Guo L, Shewade HD, Thekkur P, Zhang H, Yuan YL, Wang XM, Wang XL, Sun MM, Huang F, Zhao YL. Effect of using electronic medication monitors on tuberculosis treatment outcomes in China: a longitudinal ecological study. Infect Dis Poverty 2021; 10:29. [PMID: 33731213 PMCID: PMC7967105 DOI: 10.1186/s40249-021-00818-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/05/2021] [Indexed: 12/18/2022] Open
Abstract
Background In China, an indigenously developed electronic medication monitor (EMM) was designed and used in 138 counties from three provinces. Previous studies showed positive results on accuracy, effectiveness, acceptability, and feasibility, but also found some ineffective implementations. In this paper, we assessed the effect of implementation of EMMs on treatment outcomes. Methods The longitudinal ecological method was used at the county level with aggregate secondary programmatic data. All the notified TB cases in 138 counties were involved in this study from April 2017 to June 2019, and rifampicin-resistant cases were excluded. We fitted a multilevel model to assess the relative change in the quarterly treatment success rate with increasing quarterly EMM coverage rate, in which a mixed effects maximum likelihood regression using random intercept model was applied, by adjusting for seasonal trends, population size, sociodemographic and clinical characteristics, and clustering within counties. Results Among all 69 678 notified TB cases, the treatment success rate was slightly increased from 93.5% [95% confidence interval (CI): 93.0–94.0] in second quarter of 2018 to 94.9% (95% CI: 94.4–95.4) in second quarter of 2019 after implementing EMMs. There was a statistically significant effect between quarterly EMM coverage and treatment success rate after adjusting for potential confounders (P = 0.0036), increasing 10% of EMM coverage rate will lead to 0.2% treatment success rate augment. Besides, an increase of 10% of elderly or bacteriologically confirmed TB will lead to a decrease of 0.4% and 0.9% of the treatment success rate. Conclusions Under programmatic settings, we found a statistically significant effect between increasing coverage of EMM and treatment success rate at the county level. More prospective studies are needed to confirm the effect of using EMM on TB treatment outcomes. We suggest performing operational research on EMMs that provides real-time data under programmatic conditions in the future. ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40249-021-00818-3.
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Affiliation(s)
- Ni Wang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Lei Guo
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,The Union South-East Asia Office, New Delhi, India
| | - Pruthu Thekkur
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,The Union South-East Asia Office, New Delhi, India
| | - Hui Zhang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yan-Li Yuan
- Jilin Research Institute of Tuberculosis Control, Changchun, China
| | - Xiao-Meng Wang
- Zhejiang Province Center Disease Control and Prevention, Hangzhou, China
| | - Xiao-Lin Wang
- The Fourth People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | - Miao-Miao Sun
- Program for Appropriate Technology in Health(PATH), China Program, Shanghai, China
| | - Fei Huang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
| | - Yan-Lin Zhao
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
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14
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Wang N, Shewade HD, Thekkur P, Zhang H, Yuan Y, Wang X, Wang X, Sun M, Huang F. Do electronic medication monitors improve tuberculosis treatment outcomes? Programmatic experience from China. PLoS One 2020; 15:e0242112. [PMID: 33166361 PMCID: PMC7652336 DOI: 10.1371/journal.pone.0242112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/26/2020] [Indexed: 11/19/2022] Open
Abstract
Background In China, an indigenously developed electronic medication monitor (EMM) was used. EMM recorded each time the device was opened (no real time data), offering an indirect measure of tuberculosis treatment adherence. Previous study in China showed that the EMM uptake was satisfactory, missing adherence data were common in the information management system (25%) and shift to directly observed therapy (DOT) based on poor adherence documented by EMMs were seldom. Objectives Among people with tuberculosis notified in 30 counties (July-December 2018) where EMM supported self-administered therapy (SAT) was suggested to all eligible (no communication impairment, ambulatory), we assessed the relative differences in unfavourable outcomes and deaths among those started on EMM at baseline (within first month of diagnosis) when compared to SAT alone. Methods This was a cohort study using secondary data. We employed an intention to treat analysis, and used modified Poisson regression with robust variance estimates to assess the association. Results Of 1810 eligible people, 1047 used EMM at baseline and of them, 216 (20.1%) stopped using EMM midway. Of 763 people who did not use EMM at baseline, 267 (35.0%) started using EMM later during the treatment. Among those who started using EMM at baseline, 6.3% [95% CI: 4.9, 8.0] had unfavourable outcomes compared to 6.7% [95% CI: 5.1, 8.8] among those who did not (p = 0.746). Lesser deaths were observed in people who started EMM at baseline when compared to those who did not: 2.5% [95% CI: 1.7, 3.7] versus 3.5% [95% CI: 2.4, 5.2], p = 0.191. The lack of association remained after adjusting for potential confounders (occupation, TB classification and TB category). Conclusion Under programmatic settings, we did not find significant differences in the outcomes. Optimization of EMMs by shifting to DOT when indicated, addressing the issue of missing data and ensuring continuous use is required.
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Affiliation(s)
- Ni Wang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Hemant Deepak Shewade
- International Union against Tuberculosis and Lung Disease (The Union), Paris, France
- The Union South East Asia Office, New Delhi, India
| | - Pruthu Thekkur
- International Union against Tuberculosis and Lung Disease (The Union), Paris, France
- The Union South East Asia Office, New Delhi, India
| | - Hui Zhang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yanli Yuan
- Jilin Research Institute of Tuberculosis Control, Changchun, China
| | - Xiaomeng Wang
- Zhejiang province Center Disease Control and Prevention, Hangzhou, China
| | - Xiaolin Wang
- The Fourth People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | | | - Fei Huang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- * E-mail:
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