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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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Zia Y, Nambala L, Stalter RM, Muwonge TR, Ssebuliba T, Nakyanzi A, Nampewo O, Boyer J, Morrison S, Nsubuga R, Bagaya M, Nyanzi R, Matovu F, Yin M, Wyatt C, Mujugira A, Heffron R. Depression and PrEP uptake, interruption, and adherence among young women in Uganda. AIDS Care 2023:1-10. [PMID: 36892945 DOI: 10.1080/09540121.2023.2177250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Depression is a common cause of morbidity globally and can impact adherence to medications, posing challenges to medication-based HIV prevention. The objectives of this work are to describe the frequency of depression symptoms in a cohort of 499 young women in Kampala, Uganda and to determine the association of depression symptoms with use of HIV pre-exposure prophylaxis (PrEP). Mild or greater depression, assessed by the patient health questionnaire (PHQ-9), was experienced by 34% of participants at enrollment. Participants with mild depression symptoms tended to uptake PrEP, request PrEP refills, and adhere to PrEP with similar frequency to women with no/minimal signs of depression. These findings highlight opportunities to leverage existing HIV prevention programs to identify women who may benefit from mental health services and may not otherwise be screened.Trial registration: ClinicalTrials.gov identifier: NCT03464266..
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Affiliation(s)
- Yasaman Zia
- Departments of Epidemiology, University of Washington, Seattle, WA, USA.,Global Health, University of Washington, Seattle, WA, USA
| | - Lydia Nambala
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.,Sacramento City College, Sacramento, CA, USA
| | - Randy M Stalter
- Departments of Epidemiology, University of Washington, Seattle, WA, USA.,Global Health, University of Washington, Seattle, WA, USA
| | - Timothy R Muwonge
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Timothy Ssebuliba
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Agnes Nakyanzi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Olivia Nampewo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jade Boyer
- Global Health, University of Washington, Seattle, WA, USA
| | - Susan Morrison
- Global Health, University of Washington, Seattle, WA, USA
| | - Rogers Nsubuga
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Monica Bagaya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Robert Nyanzi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Flavia Matovu
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Michael Yin
- Department of Medicine, Division of Infectious Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Christina Wyatt
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, USA
| | - Andrew Mujugira
- Global Health, University of Washington, Seattle, WA, USA.,Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Renee Heffron
- Departments of Epidemiology, University of Washington, Seattle, WA, USA.,Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Haberer JE, Baijuka R, Tumuhairwe JB, Tindimwebwa EB, Tinkamanyire J, Tuhanamagyezi E, Musoke L, Garrison LE, DelSignore M, Musinguzi N, Asiimwe S. Implementation of Electronic Adherence Monitors and Associated Interventions for Routine HIV Antiretroviral Therapy in Uganda: Promising Findings. Front Digit Health 2022; 4:899643. [PMID: 35937420 PMCID: PMC9354256 DOI: 10.3389/fdgth.2022.899643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background High, sustained adherence is critical for achieving the individual and public health benefits of HIV antiretroviral therapy (ART). Electronic monitors provide detailed adherence information and can enable real-time interventions; however, their use to date has largely been confined to research. This pilot study (NCT03825952) sought to understand feasibility and acceptability a relatively low-cost version of this technology and associated interventions for routine ART delivery in sub-Saharan Africa. Methods We provided two ART clinics in rural, southwestern Uganda with electronic adherence monitors for data-informed counseling as well as optional SMS messages to clients and/or social supporters (daily or triggered by missed or delayed doses) and/or an alarm. Clinic and ART client experiences were observed for 3 months per client, including time and motion studies. Qualitative interviews among clients, clinicians, and healthcare administrators were informed by the Consolidated Framework for Implementation Research. Results Fifty-one ART clients were enrolled; 57% were male and the median age was 34 years. Choice of associated intervention varied among participants. The median number of visits during follow-up was two per client. Counselors reviewed the adherence data with 90% of clients at least once; 67% reviewed data at all visits. Average adherence was 94%; four clients had adherence gaps >1 week. Acceptability was high; all but one client found the monitor "very useful” and all found SMS “very useful.” Clinic visits among clients with the intervention lasted 4 min longer on average than those in standard care. The monitors and daily SMS generally functioned well, although excess SMS were triggered, primarily due to cellular network delays. Overall, participants felt the technology improved adherence, clinic experiences, and clinician-client relationships. Few worried about stigma and privacy. Cost was a concern for implementation, particularly at scale. Conclusion We successfully implemented a relatively low-cost electronic ART adherence monitor and associated interventions for routine care in rural Uganda. Feasibility and acceptability were generally high, and individuals were identified who could benefit from adherence support. Future work should involve longitudinal follow-up of diverse populations, clinical outcomes, and detailed cost-effectiveness analysis to help drive policy decisions around the uptake of this technology for routine clinical care. Clinical Trial Registration identifier: NCT03825952.
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Affiliation(s)
- Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
- *Correspondence: Jessica E. Haberer
| | | | | | | | | | | | | | - Lindsey E. Garrison
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States
| | - Marisa DelSignore
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States
| | - Nicholas Musinguzi
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States
| | - Stephen Asiimwe
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States
- Kabwohe Clinical Research Centre, Kabwohe, Uganda
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Izzah Z, Zijp TR, Åberg C, Touw DJ, van Boven JFM. Electronic Smart Blister Packages to Monitor and Support Medication Adherence: A Usability Study. Patient Prefer Adherence 2022; 16:2543-2558. [PMID: 36124125 PMCID: PMC9482437 DOI: 10.2147/ppa.s374685] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE An electronic version of the Dosepak® (EDP) which records date and time of dosing events has been developed to monitor adherence to medication packaged in blisters. This study aimed to evaluate its usability and acceptance and to monitor dose-taking adherence for optimal implementation in future clinical trials and practice. METHODS Healthy volunteers aged over 18 years were asked to dispense placebo tablets twice daily from EDPs equipped with a re-usable electronic module for a total duration of four weeks. Afterwards, subjects were asked to complete an online questionnaire and partake in a short one-on-one interview. The usability of the EDP was assessed using the System Usability Scale (SUS), while dose-taking adherence was monitored by EDP records, pill counting, and self-report. The short interview explored user experiences in more detail. RESULTS Twenty subjects with median [IQR] age 41.5 [32-49.8] years, 55% female, 45% healthcare professionals, and 20% chronic medication users completed the study and found the EDP easy to use, with a mean [SD] SUS score of 78.0 [11.2]. Median [IQR] dose-taking adherence was 89% [82-95%] based on EDP records, 96.5% [89-100%] based on pill counting, 92% [91-96%] based on self-report, and the levels differed significantly (p < 0.05). Four themes emerged from the interviews: user preference, experience, patient burden, and ideas for improvement. Most participants preferred smaller sized blisters. They found the EDP simple to use and did not see any patient burden for its use in trials or clinical practice. Some reported forgetfulness and suggested reminders built into the blister or sent to their mobile phones. Adequate information or instruction should also be provided for older people and polypharmacy patients. CONCLUSION EDP had good perceived usability, was well accepted, and differed significantly from other adherence measurement methods. This study provides input to further guide scale-up of the blister packages.
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Affiliation(s)
- Zamrotul Izzah
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Department of Pharmacy Practice, Faculty of Pharmacy, Universitas Airlangga, Surabaya, Indonesia
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Tanja R Zijp
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Christoffer Åberg
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
- Medication Adherence Expertise Center of the Northern Netherlands (MAECON), Groningen, the Netherlands
| | - Job F M van Boven
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Medication Adherence Expertise Center of the Northern Netherlands (MAECON), Groningen, the Netherlands
- Correspondence: Job FM van Boven, Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Hanzeplein 1 (Internal Postcode AP50), Groningen, 9713 GZ, the Netherlands, Tel +31 50 361 7893, Fax +31 50 361 4087, Email
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