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Sodhi R, Vatsyayan V, Panibatla V, Sayyad K, Williams J, Pattery T, Pal A. Impact of a pilot mHealth intervention on treatment outcomes of TB patients seeking care in the private sector using Propensity Scores Matching-Evidence collated from New Delhi, India. PLOS DIGITAL HEALTH 2024; 3:e0000421. [PMID: 39259731 PMCID: PMC11389929 DOI: 10.1371/journal.pdig.0000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 07/23/2024] [Indexed: 09/13/2024]
Abstract
Mobile health applications called Digital Adherence Technologies (DATs), are increasingly used for improving treatment adherence among Tuberculosis patients to attain cure, and/or other chronic diseases requiring long-term and complex medication regimens. These DATs are found to be useful in resource-limited settings because of their cost efficiency in reaching out to vulnerable groups (providing pill and clinic visit reminders, relevant health information, and motivational messages) or those staying in remote or rural areas. Despite their growing ubiquity, there is very limited evidence on how DATs improve healthcare outcomes. We analyzed the uptake of DATs in an urban setting (DS-DOST, powered by Connect for LifeTM, Johnson & Johnson) among different patient groups accessing TB services in New Delhi, India, and subsequently assessed its impact in improving patient engagement and treatment outcomes. This study aims to understand the uptake patterns of a digital adherence technology and its impact in improving follow-ups and treatment outcomes among TB patients. Propensity choice modelling was used to create balanced treated and untreated patient datasets, before applying simple ordinary least square and logistic regression methods to estimate the causal impact of the intervention on the number of follow-ups made with the patient and treatment outcomes. After controlling for potential confounders, it was found that patients who installed and utilized DS-DOST application received an average of 6.4 (95% C.I. [5.32 to 7.557]) additional follow-ups, relative to those who did not utilize the application. This translates to a 58% increase. They also had a 245% higher likelihood of treatment success (Odds ratio: 3.458; 95% C.I. [1.709 to 6.996]).
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Affiliation(s)
| | | | | | | | - Jason Williams
- Disease Management Programs, Global Public Health at Johnson & Johnson, Germany
| | - Theresa Pattery
- Disease Management Programs, Global Public Health at Johnson & Johnson, Germany
| | - Arnab Pal
- William J Clinton Foundation, New Delhi, India
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Gonçalves Tasca B, Mganga A, Leung CL, Shilugu L, Pell C, Onjare B, Luvanda N, Mleoh L, de Groot L, van Kalmthout K, Fielding K, Jerene D. Factors related to the utilization of digital adherence technologies in tuberculosis care: A qualitative study among adults in DS-TB treatment, health care providers and other key actors in Tanzania. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002795. [PMID: 39116120 PMCID: PMC11309415 DOI: 10.1371/journal.pgph.0002795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 07/06/2024] [Indexed: 08/10/2024]
Abstract
Numerous challenges, such as lengthy treatment course, side effects, and distance to healthcare facilities contribute to suboptimal Tuberculosis (TB) treatment completion. Digital adherence technologies (DATs), such as smart pillboxes and medication labels, could be an alternative to facilitate TB treatment continuation. In-depth interviews with people undergoing treatment for drug susceptible TB, health care providers (HCPs) and other key actors were conducted to evaluate their experiences with DATs in ten health facilities across four different regions in Tanzania. This study is part of a multi country cluster randomized trials conducted under the ASCENT consortium. Interviews were conducted with a total of 41 individuals, 19 people with TB and 22 HCPs and key actors. One of the main findings indicates that participants found that the daily reminders provided by the DATs, particularly the alarm from the smart pillboxes, helped in supporting treatment continuation and establishing a routine around medicine intake. DATs use was linked with reducing the financial burden of treatment, improving people with TB-HCPs relationship, and decreasing workload for HCPs. Although DATs were generally perceived as reliable, occasional technical malfunctions, such as battery depletion in smart pillboxes, were reported. The requirement of having access to a cellphone and a power source emerged as specific barriers for medication label users. This study highlights the initial willingness and sustained enthusiasm for using DATs among respondents. DATs were perceived as useful tools, aiding individuals with treatment continuation through daily reminders and fostering stronger connections with HCPs. Nevertheless, issues such as poor network connectivity and the need for access to a working cellphone posed difficulties in usage. Findings from this study suggest the potential for improvements in the technologies and indicate that a thorough assessment of people's life conditions and needs prior to treatment initiations is important to determine the suitability of providing a DAT.
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Affiliation(s)
| | - Andrew Mganga
- KNCV Tuberculosis Foundation, Dar es Salaam, Tanzania
| | | | - Lucas Shilugu
- KNCV Tuberculosis Foundation, Dar es Salaam, Tanzania
| | | | - Baraka Onjare
- KNCV Tuberculosis Foundation, Dar es Salaam, Tanzania
| | | | - Liberate Mleoh
- National Tuberculosis and Leprosy Program, Ministry of Health, Dodoma, Tanzania
| | - Liza de Groot
- KNCV Tuberculosis Foundation, The Hague, Netherlands
| | | | - Katherine Fielding
- TB Centre and Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Degu Jerene
- KNCV Tuberculosis Foundation, The Hague, Netherlands
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Leung CL, Alacapa J, Tasca BG, Villanueva AD, Masulit S, Ignacio ML, Uy KN, Pell C, van Kalmthout K, Powers R, Fielding K, Jerene D. Digital Adherence Technologies and Differentiated Care for Tuberculosis Treatment and Their Acceptability Among Persons With Tuberculosis, Health Care Workers, and Key Informants in the Philippines: Qualitative Interview Study. JMIR Hum Factors 2024; 11:e54117. [PMID: 39042889 PMCID: PMC11303897 DOI: 10.2196/54117] [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: 11/18/2023] [Revised: 04/25/2024] [Accepted: 05/01/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Digital adherence technologies (DATs) are being studied to determine their potential to support tuberculosis (TB) treatment and address the shortcomings of directly observed therapy. Previous research has shown inconclusive results on whether DATs can enhance medication adherence among persons with TB. OBJECTIVE This study aims to understand the acceptability of DATs, namely, medication labels and smart pillboxes, among persons with TB, health care workers (HCWs), and key informants (KIs) in the Philippines. The objective is to gain valuable insights that can inform the design and implementation of DATs in the Southeast Asian region, which meet the needs and preferences of end users. METHODS Persons with TB, HCWs, and KIs were recruited from intervention facilities to participate in in-depth interviews conducted between March 2022 and January 2023. These interviews were transcribed and translated into English. A thematic analysis was carried out using NVivo software (Lumivero) to identify and analyze themes. Themes were then structured within a modified social-ecological model. RESULTS A total of 25 persons with drug-sensitive TB and 20 HCWs or KIs were interviewed. Both groups emphasized that users' technology literacy level, financial conditions, and motivation to be cured determined how they interacted with the DAT. They also acknowledged that DATs helped foster their relationship with HCWs and enabled efficient treatment support. Concerning technology, persons with TB found DATs easy to use and able to reduce clinic visits. HCWs mentioned that DATs added to their workload but also allowed them to support users who missed doses. However, both groups experienced technical challenges with DATs. Regarding program implementation, users appreciated the clear explanations and demonstrations provided by HCWs. Yet, some users reported inconsistencies between DAT settings and the information provided. HCWs stressed the importance of comprehensive training and sufficient resources for effective program implementation in the future. At the community level, both groups noted that DATs and program design protected users' privacy and reduced the risk of stigma. Finally, users and HCWs shared various contextual factors that influenced their experience with DAT, including infrastructure challenges and the impact of the COVID-19 pandemic. CONCLUSIONS In the Philippines, persons with TB and HCWs showed a high level of acceptance and satisfaction with the impact of DAT and program design. They expressed a desire for the continuation of DATs. The challenges encountered underscore the need for ongoing technological development to minimize malfunctions, enhance the capacity of health facilities, and improve infrastructure. DATs have demonstrated their ability to strengthen user-HCW relationships and protect users from stigmatization. Additional efforts are required to scale up the DAT program in the Philippines.
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Affiliation(s)
| | - Jason Alacapa
- KNCV Tuberculosis Foundation Philippines, Metro Manila, Philippines
| | | | | | - Saniata Masulit
- KNCV Tuberculosis Foundation Philippines, Metro Manila, Philippines
| | | | | | | | | | | | - Katherine Fielding
- TB Centre and Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Degu Jerene
- KNCV Tuberculosis Foundation, Den Haag, Netherlands
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Zary M, Mohamed MS, Kafie C, Chilala CI, Bahukudumbi S, Foster N, Gore G, Fielding KL, Subbaraman R, Schwartzman K. The performance of digital technologies for measuring tuberculosis medication adherence: a systematic review. BMJ Glob Health 2024; 9:e015633. [PMID: 39013639 PMCID: PMC11288144 DOI: 10.1136/bmjgh-2024-015633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/21/2024] [Indexed: 07/18/2024] Open
Abstract
INTRODUCTION Digital adherence technologies (DATs), such as phone-based technologies and digital pillboxes, can provide more person-centric approaches to support tuberculosis (TB) treatment. However, there are varying estimates of their performance for measuring medication adherence. METHODS We conducted a systematic review (PROSPERO-CRD42022313526), which identified relevant published literature and preprints from January 2000 to April 2023 in five databases. Studies reporting quantitative data on the performance of DATs for measuring TB medication adherence against a reference standard, with at least 20 participants, were included. Study characteristics and performance outcomes (eg, sensitivity, specificity and predictive values) were extracted. Sensitivity was the proportion correctly classified as adherent by the DAT, among persons deemed adherent by a reference standard. Specificity was the proportion correctly classified as non-adherent by the DAT, among those deemed non-adherent by a reference standard. RESULTS Of 5692 studies identified by our systematic search, 13 met inclusion criteria. These studies investigated medication sleeves with phone calls (branded as '99DOTS'; N=4), digital pillboxes N=5), ingestible sensors (N=2), artificial intelligence-based video-observed therapy (N=1) and multifunctional mobile applications (N=1). All but one involved persons with TB disease. For medication sleeves with phone calls, compared with urine testing, reported sensitivity and specificity were 70%-94% and 0%-61%, respectively. For digital pillboxes, compared with pill counts, reported sensitivity and specificity were 25%-99% and 69%-100%, respectively. For ingestible sensors, the sensitivity of dose detection was ≥95% compared with direct observation. Participant selection was the most frequent potential source of bias. CONCLUSION The limited number of studies available suggests suboptimal and variable performance of DATs for dose monitoring, with significant evidence gaps, notably in real-world programmatic settings. Future research should aim to improve understanding of the relationships of specific technologies, settings and user engagement with DAT performance and should measure and report performance in a more standardised manner.
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Affiliation(s)
- Miranda Zary
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mona Salaheldin Mohamed
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Cedric Kafie
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Shruti Bahukudumbi
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Nicola Foster
- TB Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Genevieve Gore
- McGill Schulich Library of Physical Sciences, Life Sciences and Engineering, McGill University, Montreal, Quebec, Canada
| | | | - Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Kevin Schwartzman
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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Mtenga AE, Maro RA, Dillip A, Msoka P, Emmanuel N, Ngowi K, Sumari-de Boer M. Acceptability of a Digital Adherence Tool Among Patients With Tuberculosis and Tuberculosis Care Providers in Kilimanjaro Region, Tanzania: Mixed Methods Study. Online J Public Health Inform 2024; 16:e51662. [PMID: 38922643 PMCID: PMC11237791 DOI: 10.2196/51662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 02/27/2024] [Accepted: 05/09/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND The World Health Organization has recommended digital adherence tools (DATs) as a promising intervention to improve antituberculosis drug adherence. However, the acceptability of DATs in resource-limited settings is not adequately studied. OBJECTIVE We investigated the acceptability of a DAT among patients with tuberculosis (TB) and TB care providers in Kilimanjaro, Tanzania. METHODS We conducted a convergent parallel mixed methods study among patients with TB and TB care providers participating in our 2-arm cluster randomized trial (REMIND-TB). The trial aimed to investigate whether the evriMED pillbox with reminder cues and adherence feedback effectively improves adherence to anti-TB treatment among patients with TB in Kilimanjaro, Tanzania. We conducted exit and in-depth interviews among patients as well as in-depth interviews among TB care providers in the intervention arm. We conducted a descriptive analysis of the quantitative data from exit interviews. Translated transcripts and memos were organized using NVivo software. We employed inductive and deductive thematic framework analysis, guided by Sekhon's theoretical framework of acceptability. RESULTS Out of the 245 patients who completed treatment, 100 (40.8%) were interviewed during exit interviews, and 18 patients and 15 TB care providers were interviewed in-depth. Our findings showed that the DAT was highly accepted: 83% (83/100) expressed satisfaction, 98% (98/100) reported positive experiences with DAT use, 78% (78/100) understood how the intervention works, and 92% (92/100) successfully used the pillbox. Good perceived effectiveness was reported by 84% (84/100) of the participants who noticed improved adherence, and many preferred continuing receiving reminders through SMS text messages, indicating high levels of self-efficacy. Ethical concerns were minimal, as 85 (85%) participants did not worry about remote monitoring. However, some participants felt burdened using DATs; 9 (9%) faced difficulties keeping the device at home, 12 (12%) were not pleased with receiving daily reminder SMS text messages, and 30 (30%) reported challenges related to mobile network connectivity issues. TB care providers accepted the intervention due to its perceived impact on treatment outcomes and behavior change in adherence counseling, and they demonstrated high level of intervention coherence. CONCLUSIONS DATs are highly acceptable in Tanzania. However, some barriers such as TB-related stigma and mobile network connectivity issues may limit acceptance. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1186/s13063-019-3483-4.
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Affiliation(s)
- Alan Elias Mtenga
- mHealth Department, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
- Department of Life Science and Bioengineering, Nelson Mandela African Institution of Science and Technology, Arusha, United Republic of Tanzania
| | - Rehema Anenmose Maro
- mHealth Department, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
| | - Angel Dillip
- Department of Life Science and Bioengineering, Nelson Mandela African Institution of Science and Technology, Arusha, United Republic of Tanzania
- Department of Health system, Apotheker Health Access Initiatives, Tanzania, Dar es salaam, United Republic of Tanzania
| | - Perry Msoka
- mHealth Department, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
| | - Naomi Emmanuel
- mHealth Department, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
| | - Kennedy Ngowi
- mHealth Department, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
| | - Marion Sumari-de Boer
- mHealth Department, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
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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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Anenmose Maro R, Mtenga A, Mtesha B, Wilhelm K, Lekashingo N, Sumari-de Boer M, Ngowi K. Implementation bottlenecks of real time medication monitoring (evriMED) for improving adherence to anti-TB drugs among people with tuberculosis in Kilimanjaro, Tanzania. J Clin Tuberc Other Mycobact Dis 2024; 34:100409. [PMID: 38225942 PMCID: PMC10788294 DOI: 10.1016/j.jctube.2023.100409] [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] [Indexed: 01/17/2024] Open
Abstract
Introduction Digital Adherence Tools (DATs), which include real-time medication monitoring and Short Message Service (SMS) reminders, have been reported to improve medication adherence among people with Tuberculosis (TB). Recently, in limited resource settings, DATs have been described as a promising tool to monitor patients' medication behaviour. We aimed to determine implementation bottlenecks of real-time medication monitoring using the evriMED device. Method We conducted a research study using a mixed-methods approach, involving both people with TB s and directly observed treatment (DOT) providers who participated in the REMIND-TB trial and utilized the evriMED devices. EvriMED is a medication dispenser with internet connectivity that can send real-time SMS reminders. To gather data, we extracted reports from the Wisepill dashboard, specifically the client status report. This report documented the activity status of all devices, including communication and battery status. Additionally, we conducted in-depth interviews with people with TB and TB care providers who were involved in implementing the Remind TB trial in the Kilimanjaro region. These interviews were guided by the MIDI (Measurement Instrument for Determinants of Innovation), which helps identify the factors influencing the implementation of innovations such as evriMED. Results Out of the initial 281 participants who were given devices, 245 completed the 6-month follow-up period. The findings indicate that at month 6, most of the devices (49%) reported battery-related challenges. Additionally, forty devices (14%) had reported more than one incidence of losing communication. Through interviews with participants, we observed that evriMED was perceived as user-friendly, and the people with TB reported high satisfaction as the device facilitated improved medication intake. TB care providers also said that evriMED was a relevant tool to be used by the people with TB. However, during the in-depth interview certain implementation bottlenecks were identified, including network issues, limited training, and low technology knowledge among TB care providers, who found the procedure of using the evriMED to be time-consuming. Conclusion Implementation of evriMED was perceived as user-friendly and highly satisfactory by people with TB. Certain implementation bottlenecks were identified as potential barriers to the use of devices. These bottlenecks include network issues, limited training, battery-related challenges and low technological knowledge among TB care providers, which may have contributed to communication loss. Further research may be needed to address these limitations and develop effective strategies to facilitate the successful implementation of evriMED as a tool for improving medication intake among people with TB.
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Affiliation(s)
- Rehema Anenmose Maro
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
| | - Alan Mtenga
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
| | - Benson Mtesha
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | | | | | - Marion Sumari-de Boer
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- Kilimanjaro Christian Medical Univesity Collage, Moshi, Tanzania
- Knowledge, Innovation & Technology Group at Wageningen & University Research, the Netherlands
| | - Kennedy Ngowi
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
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Chidambaram S, Jain B, Jain U, Mwavu R, Baru R, Thomas B, Greaves F, Jayakumar S, Jain P, Rojo M, Battaglino MR, Meara JG, Sounderajah V, Celi LA, Darzi A. An introduction to digital determinants of health. PLOS DIGITAL HEALTH 2024; 3:e0000346. [PMID: 38175828 PMCID: PMC10766177 DOI: 10.1371/journal.pdig.0000346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
In recent years, technology has been increasingly incorporated within healthcare for the provision of safe and efficient delivery of services. Although this can be attributed to the benefits that can be harnessed, digital technology has the potential to exacerbate and reinforce preexisting health disparities. Previous work has highlighted how sociodemographic, economic, and political factors affect individuals' interactions with digital health systems and are termed social determinants of health [SDOH]. But, there is a paucity of literature addressing how the intrinsic design, implementation, and use of technology interact with SDOH to influence health outcomes. Such interactions are termed digital determinants of health [DDOH]. This paper will, for the first time, propose a definition of DDOH and provide a conceptual model characterizing its influence on healthcare outcomes. Specifically, DDOH is implicit in the design of artificial intelligence systems, mobile phone applications, telemedicine, digital health literacy [DHL], and other forms of digital technology. A better appreciation of DDOH by the various stakeholders at the individual and societal levels can be channeled towards policies that are more digitally inclusive. In tandem with ongoing work to minimize the digital divide caused by existing SDOH, further work is necessary to recognize digital determinants as an important and distinct entity.
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Affiliation(s)
- Swathikan Chidambaram
- Department of Surgery & Cancer, Imperial College London, St. Mary’s Hospital, London, United Kingdom
- Institute of Global Health Innovation, Imperial College London, South Kensington Campus, London, United Kingdom
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Urvish Jain
- Dietrich School of Arts and Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Rogers Mwavu
- Mbarara University of Science & Technology, Uganda
| | - Rama Baru
- Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
| | - Beena Thomas
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Felix Greaves
- Science, Evidence and Analytics, National Institute for Health and Care Excellence, England, United Kingdom
- Faculty of Medicine, School of Public Health, Imperial College London, United Kingdom
| | - Shruti Jayakumar
- Department of Surgery & Cancer, Imperial College London, St. Mary’s Hospital, London, United Kingdom
- Institute of Global Health Innovation, Imperial College London, South Kensington Campus, London, United Kingdom
| | - Pankaj Jain
- Health Plan Consumer and Provider Technology, Highmark Health, Pittsburgh, Pennsylvania, United States of America
- Department of Marketing, Indiana University of Pennsylvania, Indiana, Pennsylvania, United States of America
| | - Marina Rojo
- Public Health Innovation Lab, Med School, Buenos AIres University, Argentina
| | | | - John G. Meara
- Department of Plastic and Oral Surgery, Longwood Avenue, Boston, Massachusetts, United States of America
| | - Viknesh Sounderajah
- Department of Surgery & Cancer, Imperial College London, St. Mary’s Hospital, London, United Kingdom
- Institute of Global Health Innovation, Imperial College London, South Kensington Campus, London, United Kingdom
| | - Leo Anthony Celi
- Division of Pulmonary, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Boston, Massachusetts, United States of America
| | - Ara Darzi
- Department of Surgery & Cancer, Imperial College London, St. Mary’s Hospital, London, United Kingdom
- Institute of Global Health Innovation, Imperial College London, South Kensington Campus, London, United Kingdom
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Li W, Su M, Zhang W, Fan X, Li R, Gao Y, Wei X. Barriers and facilitators of implementing electronic monitors to improve adherence and health outcomes in tuberculosis patients: protocol for a systematic review based on the Consolidated Framework for Implementation Research. Health Res Policy Syst 2023; 21:115. [PMID: 37915089 PMCID: PMC10621129 DOI: 10.1186/s12961-023-01054-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 09/25/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) has been regarded as 'a relentless scourge', increasing morbidity and mortality and burdening vulnerable populations. Poor adherence to TB treatment and ineffective traditional interventions hinders TB control. A novel TB approach called 'electronic monitors', equipping medication boxes with daily audio or visual reminders for electronically monitoring medication intake, seems promising in improving adherence and health outcomes and overcoming the weaknesses of traditional interventions. However, no review has systematically examined and synthesized the influencing factors of implementing electronic monitors. Implementation research offers the means to analyse the influencing factors of the implementation and its process, fitting well with the aim of this review. Therefore, the widely recognized Consolidated Framework for Implementation Research (CFIR), which offers a common taxonomy for evaluating intervention implementation, will be adopted to systematically identify barriers and facilitators of the electronic monitors for improving adherence and health outcomes in patients with TB. METHODS AND ANALYSIS The systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Literature research will be conducted in five electronic databases (Ovid MEDLINE, CINAHL, EMBASE, Cochrane Library and Web of Science) to identify the barriers and facilitators of implementing electronic monitors in patients with TB. The CFIR will be used as a guide for categorizing and synthesizing the barriers and facilitators. Study screening, data extraction, quality appraisal and data analysis will be conducted by two independent reviewers. The use of additional reviewers will solve any disagreements between the two reviewers. DISCUSSION Given the increased prominence of TB epidemiology and the adherence problem of electronic monitors, there is a solid rationale for synthesizing the existing studies via the CFIR. The findings and conclusion of this review will lay bare the achievements and effectiveness of implementing electronic monitors, as well as the attendant gaps and limitations. Further strategies for facilitating the implementation of electronic monitors will also be explored. This review will be of essential significance for research and practice, supporting future academic research initiatives centred on patients with TB and aiding electronic monitor design in lowering the morbidity and mortality associated with TB disease. TRIAL REGISTRATION NUMBER PROSPERO: CRD42023395747.
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Affiliation(s)
- Wenhui Li
- School of Public Administration, Inner Mongolia University, Hohhot, China
| | - Min Su
- School of Public Administration, Inner Mongolia University, Hohhot, China.
| | - Weile Zhang
- School of Public Administration, Inner Mongolia University, Hohhot, China
| | - Xiaojing Fan
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China
| | - Renzhong Li
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yulong Gao
- Inner Mongolia Center for Disease Control and Prevention, Hohhot, China
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Mukora R, Ahumah B, Maraba N, Orrell C, Jennings L, Naidoo P, Fielding KL, Velen K, Charalambous S, Chetty-Makkan CM. Acceptability of using the medication monitor and experience of a differentiated care approach for TB treatment adherence among people living with TB in South Africa. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001885. [PMID: 37889875 PMCID: PMC10610070 DOI: 10.1371/journal.pgph.0001885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The introduction of digital adherence technologies (DATs) such as medication monitors in tuberculosis (TB) programmes supports treatment adherence among people with tuberculosis (PWTB). We evaluated the acceptability of using medication monitors (Wisepill evriMED) prompting a stepwise differentiated care approach (DCA), involving short message service (SMS), phone calls, home visits and motivational counselling, among PWTB in South Africa. METHODS We conducted 62 in-depth interviews with participants in local languages across three provinces (January-October 2020), purposively selected by treatment month, adherence history and gender. Interviews were audio recorded, transcribed verbatim and translated. Using a deductive approach and the Theoretical Framework for Acceptability (TFA), we explored acceptability across the sample attributes. RESULTS PWTB across adherence histories showed a positive attitude to using the evriMED device and receiving the DCA support. PWTB described the SMS reminders and phone calls as effective reminders, though home visits were less acceptable, due to perceived stigma. Despite willingness to participate in the intervention, the large size of the monitor and sound of the alarm drew attention, potentially causing embarrassment and stigma. Due to perceived stigma, some PWTB adapted the intervention by leaving the monitor at home after removing the pills to ensure that someone else tracked usage, while the PWTB used alternative reminders such as cell phones to take their medication. CONCLUSION Although PWTB showed a positive attitude towards the intervention, perceived stigma contributed to participants adapting their lifestyle to meet treatment adherence requirements without using the monitor. However, the medication monitor was a tool that seemed to prompt this personal change in behaviour. Achieving people-centered TB care, including the introduction of DATs, will require that TB programmes incorporate PWTB insights to maximize their use and effectiveness.
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Affiliation(s)
- Rachel Mukora
- The Aurum Institute, Aurum House, Parktown, Johannesburg, South Africa
- University of Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Barack Ahumah
- University of Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Noriah Maraba
- The Aurum Institute, Aurum House, Parktown, Johannesburg, South Africa
| | - Catherine Orrell
- Department of Medicine, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Desmond Tutu Health Foundation, Cape Town, South Africa
| | | | - Pren Naidoo
- Stellenbosch University, Stellenbosch, South Africa
| | - Katherine L. Fielding
- University of Witwatersrand, School of Public Health, Johannesburg, South Africa
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kavindhran Velen
- The Aurum Institute, Aurum House, Parktown, Johannesburg, South Africa
| | - Salome Charalambous
- The Aurum Institute, Aurum House, Parktown, Johannesburg, South Africa
- University of Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Candice M. Chetty-Makkan
- Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
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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: 1] [Impact Index Per Article: 1.0] [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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12
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Mukora R, Maraba N, Orrell C, Jennings L, Naidoo P, Mbatha MT, Velen K, Fielding K, Charalambous S, Chetty-Makkan CM. Qualitative study exploring the feasibility of using medication monitors and a differentiated care approach to support adherence among people receiving TB treatment in South Africa. BMJ Open 2023; 13:e065202. [PMID: 36868589 PMCID: PMC9990642 DOI: 10.1136/bmjopen-2022-065202] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 02/21/2023] [Indexed: 03/05/2023] Open
Abstract
OBJECTIVES The tuberculosis (TB) MATE study evaluated whether a differentiated care approach (DCA) based on tablet-taking data from Wisepill evriMED digital adherence technology could improve TB treatment adherence. The DCA entailed a stepwise increase in adherence support starting from short message service (SMS) to phone calls, followed by home visits and motivational counselling. We explored feasibility of this approach with providers in implementing clinics. DESIGN Between June 2020 and February 2021, in-depth interviews were conducted in the provider's preferred language, audiorecorded, transcribed verbatim and translated. The interview guide included three categories: feasibility, system-level challenges and sustainability of the intervention. We assessed saturation and used thematic analysis. SETTING Primary healthcare clinics in three provinces of South Africa. PARTICIPANTS We conducted 25 interviews with 18 staff and 7 stakeholders. RESULTS Three major themes emerged: First, providers were supportive of the intervention being integrated into the TB programme and were eager to be trained on the device as it helped to monitor treatment adherence. Second, there were challenges in the adoption system such as shortage of human resources which could serve as a barrier to information provision once the intervention is scaled up. Healthcare workers reported that some patients received incorrect SMS's due to delays in the system that contributed to distrust. Third, DCA was considered as a key aspect of the intervention by some staff and stakeholders since it allowed for support based on individual needs. CONCLUSIONS It was feasible to monitor TB treatment adherence using the evriMED device and DCA. To ensure successful scale-up of the adherence support system, emphasis will need to be placed on ensuring that the device and the network operate optimally and continued support on adhering to treatment which will enable people with TB to take ownership of their treatment journey and help overcome TB-related stigma. TRIAL REGISTRATION NUMBER Pan African Trial Registry PACTR201902681157721.
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Affiliation(s)
- Rachel Mukora
- The Aurum Institute, Implementation Research Division, Johannesburg, South Africa
- University of Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Noriah Maraba
- The Aurum Institute, Implementation Research Division, Johannesburg, South Africa
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, Institute of Infectious Disease and Molecular Medicine and the Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lauren Jennings
- Desmond Tutu HIV Foundation, Institute of Infectious Disease and Molecular Medicine and the Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Pren Naidoo
- University of Stellenbosch, Stellenbosch, South Africa
| | - M Thulani Mbatha
- Interactive Research and Development, Johannesburg, South Africa
| | - Kavindhran Velen
- The Aurum Institute, Implementation Research Division, Johannesburg, South Africa
| | | | - Salome Charalambous
- The Aurum Institute, Implementation Research Division, Johannesburg, South Africa
- University of Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Candice Maylene Chetty-Makkan
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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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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Saha S, Saxena D, Raval D, Halkarni N, Doshi R, Joshi M, Sridharan M, Sathwara J, Yasobant S, Shah H, Quazi ZS, Rajsekar K, Chowdhury J. Tuberculosis Monitoring Encouragement Adherence Drive (TMEAD): Toward improving the adherence of the patients with drug-sensitive tuberculosis in Nashik, Maharashtra. Front Public Health 2022; 10:1021427. [PMID: 36620234 PMCID: PMC9812554 DOI: 10.3389/fpubh.2022.1021427] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/18/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Adherence to tuberculosis (TB) medication is one of the critical challenges to tuberculosis elimination in India. Digital adherence technologies (DAT) have the potential to facilitate medication adherence and monitor it remotely. Tuberculosis Monitoring Encouragement Adherence Drive (TMEAD) is one such DAT piloted in Nasik, Maharashtra, from April 2020 to December 2021. The study aims to assess the adherence and cost-effectiveness of TMEAD compared to the standard of care among patients with drug-sensitive tuberculosis (DSTB) residing in the urban areas of Nasik, Maharashtra, India. Methods A quasi-experimental study was conducted among new cases of TB as per the National TB Elimination Programme (NTEP) residing in the urban geography of Nasik. The intervention and control arms were purposively selected from non-contaminating TB units (TUs). A total of 400 DSTB patients (200 in the intervention group and 200 in the control group) were enrolled. After enrolment, patients in the intervention arm were provided with the TMEAD device and followed for 24 weeks to assess treatment outcomes. Adherence was measured as those patients who have completed 80% of prescribed doses, as reported during patient follow-up, and further validated by analyzing the trace of rifampicin in urine among 20% of patients from both arms. A budget impact analysis was done to assess the impact of the TMEAD program on the overall state health budget. Results Out of 400 enrolled DSTB patients, 261 patients completed treatment, 108 patients were on treatment, 15 patients died, and 16 patients were defaulters over the study period. The study reported overall treatment adherence of 94% among those who completed treatment. Patient reports indicated high levels of treatment adherence in the intervention group (99%) as compared to the control group (90%). Adherence assessed through analyzing trace of rifampicin in the urine sample for the intervention arm was 84% compared to the control arm (80%). Per beneficiary (discounted) cost for TMEAD was Indian rupees (INR) 6,573 (USD 83). The incremental cost-effectiveness ratio of the intervention is INR 11,599 (USD 146), which shows that the intervention is highly cost-effective. Conclusion This study revealed that patient-reported treatment adherence was high in TMEAD when compared to standard therapy of care for DSTB patients and the intervention is cost-effective. TMEAD could complement the national strategy to end TB by improving adherence to the treatment regimen in India.
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Affiliation(s)
- Somen Saha
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, Gujarat, India,School of Epidemiology and Public Health, Datta Meghe Institute of Medical Sciences (DMIMS), Wardha, Maharashtra, India,*Correspondence: Somen Saha
| | - Deepak Saxena
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, Gujarat, India,School of Epidemiology and Public Health, Datta Meghe Institute of Medical Sciences (DMIMS), Wardha, Maharashtra, India
| | - Devang Raval
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, Gujarat, India
| | | | | | | | | | - Jignasa Sathwara
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, Gujarat, India
| | - Sandul Yasobant
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, Gujarat, India,School of Epidemiology and Public Health, Datta Meghe Institute of Medical Sciences (DMIMS), Wardha, Maharashtra, India
| | - Harsh Shah
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, Gujarat, India
| | - Zahiruddin Syed Quazi
- School of Epidemiology and Public Health, Datta Meghe Institute of Medical Sciences (DMIMS), Wardha, Maharashtra, India
| | - Kavitha Rajsekar
- Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi, India
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15
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Vaz C, Jose NK, Tom JJ, Goodman GR, Lee JS, Padappayil RP, Madathil M, O'Cleirigh C, Rodrigues R, Chai PR. Formative acceptance of ingestible biosensors to measure adherence to TB medications. BMC Infect Dis 2022; 22:754. [PMID: 36171553 PMCID: PMC9517983 DOI: 10.1186/s12879-022-07756-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 09/26/2022] [Indexed: 11/26/2022] Open
Abstract
Background Tuberculosis (TB) represents a significant public health threat in India. Adherence to antitubercular therapy (ATT) is the key to reducing the burden of this infectious disease. Suboptimal adherence to ATT and lack of demonstrated feasibility of current strategies for monitoring ATT adherence highlights the need for alternative adherence monitoring systems.
Methods A quantitative survey was conducted to assess the acceptance of and willingness to use a digital pill system (DPS) as a tool for monitoring ATT adherence among stakeholders directly involved in the management of patients with TB in India. Participants reviewed a video explaining the DPS and completed a survey, which covered sociodemographics, degree of involvement with TB patients, initial impressions of the DPS, and perceived challenges for deploying the technology in India. Participants were also asked to interpret mock DPS adherence data. Results The mean age was 34.3 (SD = 7.3), and participants (N = 50) were predominantly male (70%). The sample comprised internists (52%) and pulmonologists (30%), with a median of 4 years’ experience (IQR 3, 6) in the management of TB patients. No participants had previously used a DPS, but some reported prior awareness of the technology (22%). Most reported that they would recommend use of a DPS to patients on ATT (76%), and that they would use a DPS in both the intensive and continuation phases of TB management (64%). The majority viewed the DPS (82%) as a useful alternative to directly observed therapy-short course (DOTS), particularly given the ongoing COVID-19 pandemic. Participants reported that a DPS would be most effective in patients at risk of nonadherence (64%), as well as those with past nonadherence (64%). Perceived barriers to DPS implementation included lack of patient willingness (92%), cost (86%), and infrastructure constraints (66%). The majority of participants were able to accurately interpret patterns of adherence (80%), suboptimal adherence (90%), and frank nonadherence (82%) when provided with mock DPS data. Conclusions DPS are viewed as an acceptable, feasible, and useful technology for monitoring ATT adherence by stakeholders directly involved in TB management. Future investigations should explore patient acceptance of DPS and pilot demonstration of the system in the TB context. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07756-x.
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Affiliation(s)
- Clint Vaz
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02114, USA.,Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA
| | - Nisha K Jose
- Division of Non-Communicable Diseases, Indian Council of Medical Research, HQs, New Delhi, India
| | - Jeremiah Jacob Tom
- Department of Gastroenterology, Amala Institute of Medical Sciences, Thrissur, Kerala, India
| | - Georgia R Goodman
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02114, USA.,The Fenway Institute, Fenway Health, Boston, MA, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jasper S Lee
- The Fenway Institute, Fenway Health, Boston, MA, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | | | - Manjunath Madathil
- Department of Dermatology, Amala Institute of Medical Sciences, Thrissur, Kerala, India.,Department of Dermatology, Imbichibava Memorial Co-Operative Hospital and Research Center, Malappuram, Kerala, India
| | - Conall O'Cleirigh
- The Fenway Institute, Fenway Health, Boston, MA, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Rashmi Rodrigues
- Department of Community Health, St. John's Medical College, St. John's Research Institute, Bangalore, India
| | - Peter R Chai
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02114, USA. .,Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA. .,The Fenway Institute, Fenway Health, Boston, MA, USA. .,Koch Institute for Integrated Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA.
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Fahrni ML, Saman KM, Alkhoshaiban AS, Naimat F, Ramzan F, Isa KAM. Patient-reported outcome measures to detect intentional, mixed, or unintentional non-adherence to medication: a systematic review. BMJ Open 2022; 12:e057868. [PMID: 36123061 PMCID: PMC9486224 DOI: 10.1136/bmjopen-2021-057868] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 07/03/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To categorise patient-reported outcome measures (PROMs) into their propensity to detect intentional and/or unintentional non-adherence to medication, and synthesise their psychometric properties. DESIGN Systematic review and regression analysis. ELIGIBILITY Medication adherence levels studied at primary, secondary and tertiary care settings. Self-reported measures with scoring methods were included. Studies without proxy measures were excluded. DATA SOURCES Using detailed searches with key concepts including questionnaires, reliability and validity, and restricted to English, MEDLINE, EMBASE, CINAHL, International Pharmaceutical Abstracts, and Cochrane Library were searched until 01 March 2022. Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA-2020) checklist was used. DATA ANALYSIS Risk of bias was assessed via COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN-2018) guidelines. Narrative synthesis aided by graphical figures and statistical analyses. OUTCOME MEASURES Process domains [behaviour (e.g., self-efficacy), barrier (e.g., impaired dexterity) or belief (e.g., perception)], and overall outcome domains of either intentional (I), unintentional (UI), or mixed non-adherence. RESULTS Paper summarises evidence from 59 studies of PROMs, validated among patients aged 18-88 years in America, the United Kingdom, Europe, Middle East, and Australasia. PROMs detected outcome domains: intentional non-adherence, n=44 (I=491 criterion items), mixed intentionality, n=13 (I=79/UI=50), and unintentional, n=2 (UI=5). Process domains detected include belief (383 criterion items), barrier (192) and behaviour (165). Criterion validity assessment used proxy measures (biomarkers, e-monitors), and scoring was ordinal, dichotomised, or used Visual Analogue Scale. Heterogeneity was revealed across psychometric properties (consistency, construct, reliability, discrimination ability). Intentionality correlated positively with negative beliefs (r(57)=0.88) and barriers (r(57)=0.59). For every belief or barrier criterion-item, PROMs' aptitude to detect intentional non-adherence increased by β=0.79 and β=0.34 units, respectively (R2=0.94). Primary care versus specialised care predicted intentional non-adherence (OR 1.9; CI 1.01 to 2.66). CONCLUSIONS Ten PROMs had adequate psychometric properties. Of the ten, eight PROMs were able to detect total, and two PROMs were able to detect partial intentionality to medication default. Fortification of patients' knowledge and illness perception, as opposed to daily reminders alone, is most imperative at primary care levels.
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Affiliation(s)
- Mathumalar Loganathan Fahrni
- Faculty of Pharmacy, Universiti Teknologi MARA, Puncak Alam Campus, Selangor, Malaysia
- Collaborative Drug Discovery Research (CDDR) Group, Pharmaceutical Life Sciences Community of Research, Universiti Teknologi MARA, Puncak Alam, Malaysia
| | - Kamaliah Md Saman
- Faculty of Pharmacy, Universiti Teknologi MARA, Puncak Alam Campus, Selangor, Malaysia
| | | | - Faiza Naimat
- Faculty of Pharmacy, Universiti Teknologi MARA, Puncak Alam Campus, Selangor, Malaysia
| | - Farzan Ramzan
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Khairil Anuar Md Isa
- Faculty of Health Sciences, Universiti Teknologi MARA, Puncak Alam Campus, Selangor, Malaysia
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Addo J, Pearce D, Metcalf M, Lundquist C, Thomas G, Barros-Aguirre D, Koh GCKW, Strange M. Living with tuberculosis: a qualitative study of patients’ experiences with disease and treatment. BMC Public Health 2022; 22:1717. [PMID: 36085073 PMCID: PMC9462890 DOI: 10.1186/s12889-022-14115-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 08/30/2022] [Indexed: 02/06/2023] Open
Abstract
Abstract
Background
Although tuberculosis (TB) is a curable disease, treatment is complex and prolonged, requiring considerable commitment from patients. This study aimed to understand the common perspectives of TB patients across Brazil, Russia, India, China, and South Africa throughout their disease journey, including the emotional, psychological, and practical challenges that patients and their families face.
Methods
This qualitative market research study was conducted between July 2020 and February 2021. Eight TB patients from each country (n = 40) completed health questionnaires, video/telephone interviews, and diaries regarding their experiences of TB. Additionally, 52 household members were interviewed. Patients at different stages of their TB treatment journey, from a range of socioeconomic groups, with or without TB risk factors were sought. Anonymized data underwent triangulation and thematic analysis by iterative coding of statements.
Results
The sample included 23 men and 17 women aged 13–60 years old, with risk factors for TB reported by 23/40 patients. Although patients were from different countries and cultural backgrounds, experiencing diverse health system contexts, five themes emerged as common across the sample. 1) Economic hardship from loss of income and medical/travel expenses. 2) Widespread stigma, delaying presentation and deeply affecting patients’ emotional wellbeing. 3) TB and HIV co-infection was particularly challenging, but increased TB awareness and accelerated diagnosis. 4) Disruption to family life strained relationships and increased patients’ feelings of isolation and loneliness. 5) The COVID-19 pandemic made it easier for TB patients to keep their condition private, but disrupted access to services.
Conclusions
Despite disparate cultural, socio-economic, and systemic contexts across countries, TB patients experience common challenges. A robust examination of the needs of individual patients and their families is required to improve the patient experience, encourage adherence, and promote cure, given the limitations of current treatment.
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Fadahunsi KP, Wark PA, Mastellos N, Gallagher J, Majeed A, Car J. Clinical information quality of digital health technologies: protocol for an international eDelphi study. BMJ Open 2022; 12:e057430. [PMID: 35459673 PMCID: PMC9036461 DOI: 10.1136/bmjopen-2021-057430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Digital health technologies (DHTs) such as electronic health records, clinical decision support systems and electronic prescribing systems are widely used in healthcare. While adoption of DHTs can improve healthcare delivery, information quality (IQ) problems associated with DHTs can compromise quality and safety of care. The clinical information quality (CLIQ) framework for digital health is a novel approach to assessing the quality of clinical information from DHTs. This study aims to appraise the CLIQ framework by exploring clinicians' perspectives on the relevance, definition and assessment of IQ dimensions as defined in the framework. This study will adapt the CLIQ framework to the needs of clinical information users-the clinicians. The contextualised CLIQ framework will offer a pragmatic approach to assessing clinical information from DHTs and may help to forestall IQ problems that can compromise quality and safety of care. METHODS AND ANALYSIS The electronic Delphi (eDelphi) approach will be used to engage a heterogeneous group of clinicians with patient-facing and/or information governance roles recruited through purposive and snowball sampling techniques. A semi-structured online questionnaire will be used to explore clinicians' perspectives on relevance, definition and assessment of IQ dimensions in the CLIQ framework. Survey responses on the relevance of dimensions will be summarised using descriptive statistics to inform decisions on retention of dimensions and termination of the study, based on pre-specified rules. Analysis of the free-text responses will be used to revise definition and assessment of dimensions. ETHICS AND DISSEMINATION Ethics approval has been obtained from the Imperial College Research Governance and Integrity Team (Imperial College Research Ethics Committee (ICREC) Reference number: 20IC6396). The results of the study will be published in a peer-reviewed journal and presented at scientific conferences.
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Affiliation(s)
- Kayode Philip Fadahunsi
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Petra A Wark
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
- Centre for Intelligent Healthcare, Institute for Health and Wellbeing, Coventry University, Coventry, UK
| | - Nikolaos Mastellos
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Joseph Gallagher
- gHealth Research Group, School of Medicine, University College Dublin, Dublin, Ireland
| | - Azeem Majeed
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Josip Car
- Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
- Centre for Population Health Sciences, LKC Medicine, Nanyang Technological University, Singapore
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19
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Garcia-Cremades M, Solans BP, Strydom N, Vrijens B, Pillai GC, Shaffer C, Thomas B, Savic RM. Emerging Therapeutics, Technologies, and Drug Development Strategies to Address Patient Nonadherence and Improve Tuberculosis Treatment. Annu Rev Pharmacol Toxicol 2021; 62:197-210. [PMID: 34591605 DOI: 10.1146/annurev-pharmtox-041921-074800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Imperfect medication adherence remains the biggest predictor of treatment failure for patients with tuberculosis. Missed doses during treatment lead to relapse, tuberculosis resistance, and further spread of disease. Understanding individual patient phenotypes, population pharmacokinetics, resistance development, drug distribution to tuberculosis lesions, and pharmacodynamics at the site of infection is necessary to fully measure the impact of adherence on patient outcomes. To decrease the impact of expected variability in drug intake on tuberculosis outcomes, an improvement in patient adherence and new forgiving regimens that protect against missed doses are needed. In this review, we summarize emerging technologies to improve medication adherence in clinical practice and provide suggestions on how digital adherence technologies can be incorporated in clinical trials and practice and the drug development pipeline that will lead to more forgiving regimens and benefit patients suffering from tuberculosis. Expected final online publication date for the Annual Review of Pharmacology and Toxicology, Volume 62 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Maria Garcia-Cremades
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California 94158, USA;
| | - Belen P Solans
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California 94158, USA;
| | - Natasha Strydom
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California 94158, USA;
| | - Bernard Vrijens
- AARDEX Group, B-4102 Liège Science Park, Belgium.,Department of Public Health, University of Liège, B-4000 Liège, Belgium
| | - Goonaseelan Colin Pillai
- Division of Clinical Pharmacology, University of Cape Town, Observatory 7925, South Africa.,CP+ Associates GmbH, Basel 4102, Switzerland
| | - Craig Shaffer
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California 94158, USA;
| | | | - Rada M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California 94158, USA;
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Subbaraman R, Thomas BE, Kumar JV, Thiruvengadam K, Khandewale A, Kokila S, Lubeck-Schricker M, Ranjith Kumar M, Gaurkhede GR, Walgude AS, Hephzibah Mercy J, Kumbhar JD, Eliasziw M, Mayer KH, Haberer JE. Understanding Nonadherence to Tuberculosis Medications in India Using Urine Drug Metabolite Testing: A Cohort Study. Open Forum Infect Dis 2021; 8:ofab190. [PMID: 34250181 PMCID: PMC8262681 DOI: 10.1093/ofid/ofab190] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/13/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Poor adherence to tuberculosis (TB) treatment is associated with disease recurrence and death. Little research has been conducted in India to understand TB medication nonadherence. METHODS We enrolled adult drug-susceptible TB patients, approximately half of whom were people with human immunodeficiency virus (PWH), in Chennai, Vellore, and Mumbai. We conducted a single unannounced home visit to administer a survey assessing reasons for nonadherence and collect a urine sample that was tested for isoniazid content. We described patient-reported reasons for nonadherence and identified factors associated with nonadherence (ie, negative urine test) using multivariable logistic regression. We also assessed the association between nonadherence and treatment outcomes. RESULTS Of 650 participants in the cohort, 77 (11.8%) had a negative urine test. Nonadherence was independently associated with daily wage labor (adjusted odds ratio [aOR], 2.7; confidence interval [CI], 1.1-6.5; P = .03), the late continuation treatment phase (aOR, 2.0; CI, 1.1-3.9; P = .03), smear-positive pulmonary disease (aOR, 2.1; CI, 1.1-3.9; P = .03), alcohol use (aOR, 2.5; CI, 1.2-5.2; P = .01), and spending ≥30 minutes collecting medication refills (aOR, 6.6; CI, 1.5-29.5; P = .01). People with HIV reported greater barriers to collecting medications than non-PWH. Among 167 patients reporting missing doses, reported reasons included traveling from home, forgetting, feeling depressed, and running out of pills. The odds of unfavorable treatment outcomes were 4.0 (CI, 2.1-7.6) times higher among patients with nonadherence (P < .0001). CONCLUSION Addressing structural and psychosocial barriers will be critical to improve TB treatment adherence in India. Urine isoniazid testing may help identify nonadherent patients to facilitate early intervention during treatment.
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Affiliation(s)
- Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts
University School of Medicine, Boston,
Massachusetts, USA
- Division of Geographic Medicine and Infectious Diseases,
Tufts Medical Center, Boston,
Massachusetts, USA
| | - 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
| | - Kannan Thiruvengadam
- Department of Social and Behavioural Research,
ICMR-National Institute for Research in Tuberculosis,
Chennai, India
| | - Amit Khandewale
- 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
| | - Maya Lubeck-Schricker
- Department of Public Health and Community Medicine, Tufts
University School of Medicine, Boston,
Massachusetts, USA
| | - M Ranjith Kumar
- 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
| | - Apurva Shashikant Walgude
- 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
| | - Jagannath Dattatraya Kumbhar
- Department of Social and Behavioural Research,
ICMR-National Institute for Research in Tuberculosis,
Chennai, India
| | - Misha Eliasziw
- Department of Public Health and Community Medicine, 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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