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Stecher C, Chen CH, Codella J, Cloonan S, Hendler J. Combining anchoring with financial incentives to increase physical activity: a randomized controlled trial among college students. J Behav Med 2024:10.1007/s10865-024-00492-4. [PMID: 38704776 DOI: 10.1007/s10865-024-00492-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 04/16/2024] [Indexed: 05/07/2024]
Abstract
The purpose of this study was to: (1) compare the relative efficacy of different combinations of three behavioral intervention strategies (i.e., personalized reminders, financial incentives, and anchoring) for establishing physical activity habits using an mHealth app and (2) to examine the effects of these different combined interventions on intrinsic motivation for physical activity and daily walking habit strength. A four-arm randomized controlled trial was conducted in a sample of college students (N = 161) who had a self-reported personal wellness goal of increasing their physical activity. Receiving cue-contingent financial incentives (i.e., incentives conditional on performing physical activity within ± one hour of a prespecified physical activity cue) combined with anchoring resulted in the highest daily step counts and greatest odds of temporally consistent walking during both the four-week intervention and the full eight-week study period. Cue-contingent financial incentives were also more successful at increasing physical activity and maintaining these effects post-intervention than traditional non-cue-contingent incentives. There were no differences in intrinsic motivation or habit strength between study groups at any time point. Financial incentives, particularly cue-contingent incentives, can be effectively used to support the anchoring intervention strategy for establishing physical activity habits. Moreover, mHealth apps are a feasible method for delivering the combined intervention technique of financial incentives with anchoring.
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Stabile AJ, Iribarren S, Sonney J, Demiris G, Schnall R. Usability testing of a mobile health application to support individuals with active tuberculosis: a mixed methods study. Inform Health Soc Care 2024:1-13. [PMID: 38529729 DOI: 10.1080/17538157.2024.2333379] [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: 03/27/2024]
Abstract
Poor adherence to tuberculosis (TB) treatment leads to further disease transmission, worsened outcomes, and the development of drug resistance. Digital adherence technologies may facilitate a more patient-centered approach for improving TB treatment outcomes than current strategies. The objective of this study was to evaluate and explore improving usability of the TB Treatment Support Tools (TB-TST) mobile application. We used an iterative convergent mixed-method design consisting of two quantitative surveys and a qualitative think-aloud interview. Testing was conducted in three testing cycles consisting of a total of 16 interviews and 26 surveys. Results were thematically analyzed and reported to the development team during weekly team meetings. Participants rated the TB-TSTs application as having high usability and the iterative approach resulted in several refinements to the application in response to participant feedback. These refinements were well received during qualitative interviews but did not result in a statistically significant improvement in usability testing scores between cycles. Using an iterative convergent mixed-method design was an effective method for refining our mHealth application. Data collected from think-aloud interviews, the MAUQ, and the Health-ITUES identified key areas of application design that needed refinement.
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Affiliation(s)
- Alexander John Stabile
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - Sarah Iribarren
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - Jennifer Sonney
- Child, Family, and Population Health Nursing, University of Washington, Seattle, Washington, USA
| | - George Demiris
- Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca Schnall
- School of Nursing, Columbia University, New York City, New York, USA
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Walker EF, Flook M, Rodger AJ, Fielding KL, Stagg HR. Quantifying non-adherence to anti-tuberculosis treatment due to early discontinuation: a systematic literature review of timings to loss to follow-up. BMJ Open Respir Res 2024; 11:e001894. [PMID: 38359965 PMCID: PMC10875541 DOI: 10.1136/bmjresp-2023-001894] [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: 06/20/2023] [Accepted: 12/15/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND The burden of non-adherence to anti-tuberculosis (TB) treatment is poorly understood. One type is early discontinuation, that is, stopping treatment early. Given the implications of early discontinuation for treatment outcomes, we undertook a systematic review to estimate its burden, using the timing of loss to follow-up (LFU) as a proxy measure. METHODS Web of Science, Embase and Medline were searched up to 14 January 2021 using terms covering LFU, TB and treatment. Studies of adults (≥ 18 years) on the standard regimen for drug-sensitive TB reporting the timing of LFU (WHO definition) were included. A narrative synthesis was conducted and quality assessment undertaken using an adapted version of Downs and Black. Papers were grouped by the percentage of those who were ultimately LFU who were LFU by 2 months. Three groups were created: <28.3% LFU by 2 months, ≥28.3-<38.3%, ≥38.3%). The percentage of dose-months missed due to early discontinuation among (1) those LFU, and (2) all patients was calculated. RESULTS We found 40 relevant studies from 21 countries. The timing of LFU was variable within and between countries. 36/40 papers (90.0%) reported the percentage of patients LFU by the end of 2 months. 31/36 studies (86.1%) reported a higher than or as expected percentage of patients becoming LFU by 2 months. The percentage of dose-months missed by patients who became LFU ranged between 37% and 77% (equivalent to 2.2-4.6 months). Among all patients, the percentage of dose-months missed ranged between 1% and 22% (equivalent to 0.1-1.3 months). CONCLUSIONS A larger than expected percentage of patients became LFU within the first 2 months of treatment. These patients missed high percentages of dose months of treatment due to early discontinuation. Interventions to promote adherence and retain patients in care must not neglect the early months of treatment. PROSPERO REGISTRATION NUMBER CRD42021218636.
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Affiliation(s)
| | - Mary Flook
- Faculty of Life and Health Sciences, University of Liverpool, Liverpool, UK
| | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
| | - Katherine L Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, University of the Witwatersrand- Johannesburg, Johannesburg, South Africa
| | - Helen R Stagg
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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4
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Sekandi JN, McDonald A, Nakkonde D, Zalwango S, Kasiita V, Kaggwa P, Kakaire R, Atuyambe L, Buregyeya E. Acceptability, Usefulness, and Ease of Use of an Enhanced Video Directly Observed Treatment System for Supporting Patients With Tuberculosis in Kampala, Uganda: Explanatory Qualitative Study. JMIR Form Res 2023; 7:e46203. [PMID: 37948121 PMCID: PMC10674141 DOI: 10.2196/46203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 10/12/2023] [Accepted: 10/14/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND In tuberculosis (TB) control, nonadherence to treatment persists as a barrier. The traditional method of ensuring adherence, that is, directly observed therapy, faces significant challenges that hinder its widespread adoption. Digital adherence technologies such as video directly observed therapy (VDOT) are emerging as promising solutions. However, as these novel technologies gain momentum, a critical gap is the lack of comprehensive studies evaluating their efficacy and the unique experiences of patients in Africa. OBJECTIVE The aim of this study was to assess patients' experiences that affected acceptability, usefulness, and ease of use with an enhanced VDOT system during monitoring of TB treatment. METHODS We conducted individual open-ended interviews in a cross-sectional exit qualitative study in Kampala, Uganda. Thirty participants aged 18-65 years who had completed the VDOT randomized trial were purposively selected to represent variability in sex, adherence level, and HIV status. We used a hybrid process of deductive and inductive coding to identify content related to the experience of study participation with VDOT. Codes were organized into themes and subthemes, which were used to develop overarching categories guided by constructs adapted from the modified Technology Acceptance Model for Resource-Limited Settings. We explored participants' experiences regarding the ease of use and usefulness of VDOT, thereby identifying the facilitators and barriers to its acceptability. Perceived usefulness refers to the benefits users expect from the technology, while perceived ease of use refers to how easily users navigate its various features. We adapted by shifting from assessing perceived to experienced constructs. RESULTS The participants' mean age was 35.3 (SD 12) years. Of the 30 participants, 15 (50%) were females, 13 (43%) had low education levels, and 22 (73%) owned cellphones, of which 10 (45%) had smartphones. Nine (28%) were TB/HIV-coinfected, receiving antiretroviral therapy. Emergent subthemes for facilitators of experienced usefulness and ease of VDOT use were SMS text message reminders, technology training support to patients by health care providers, timely patient-provider communication, family social support, and financial incentives. TB/HIV-coinfected patients reported the added benefit of adherence support for their antiretroviral medication. The external barriers to VDOT's usefulness and ease of use were unstable electricity, technological malfunctions in the app, and lack of cellular network coverage in rural areas. Concerns about stigma, disease disclosure, and fear of breach in privacy and confidentiality affected the ease of VDOT use. CONCLUSIONS Overall, participants had positive experiences with the enhanced VDOT. They found the enhanced VDOT system user-friendly, beneficial, and acceptable, particularly due to the supportive features such as SMS text message reminders, incentives, technology training by health care providers, and family support. However, it is crucial to address the barriers related to technological infrastructure as well as the privacy, confidentiality, and stigma concerns related to VDOT.
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Affiliation(s)
- Juliet Nabbuye Sekandi
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA, United States
- Global Health Institute, University of Georgia, Athens, GA, United States
| | - Adenike McDonald
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA, United States
- Global Health Institute, University of Georgia, Athens, GA, United States
| | | | - Sarah Zalwango
- School of Public Health, Makerere University, Kampala, Uganda
- Directorate of Public Health Services and Environment, Kampala Capital City Authority, Kampala, Uganda
| | - Vicent Kasiita
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Patrick Kaggwa
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA, United States
- Global Health Institute, University of Georgia, Athens, GA, United States
| | - Robert Kakaire
- Global Health Institute, University of Georgia, Athens, GA, United States
| | - Lynn Atuyambe
- School of Public Health, Makerere University, Kampala, Uganda
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Lucà F, Oliva F, Abrignani MG, Di Fusco SA, Parrini I, Canale ML, Giubilato S, Cornara S, Nesti M, Rao CM, Pozzi A, Binaghi G, Maloberti A, Ceravolo R, Bisceglia I, Rossini R, Temporelli PL, Amico AF, Calvanese R, Gelsomino S, Riccio C, Grimaldi M, Colivicchi F, Gulizia MM. Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios. J Clin Med 2023; 12:5955. [PMID: 37762897 PMCID: PMC10531873 DOI: 10.3390/jcm12185955] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
It is well established that direct oral anticoagulants (DOACs) are the cornerstone of anticoagulant strategy in atrial fibrillation (AF) and venous thromboembolism (VTE) and should be preferred over vitamin K antagonists (VKAs) since they are superior or non-inferior to VKAs in reducing thromboembolic risk and are associated with a lower risk of intracranial hemorrhage (IH). In addition, many factors, such as fewer pharmacokinetic interactions and less need for monitoring, contribute to the favor of this therapeutic strategy. Although DOACs represent a more suitable option, several issues should be considered in clinical practice, including drug-drug interactions (DDIs), switching to other antithrombotic therapies, preprocedural and postprocedural periods, and the use in patients with chronic renal and liver failure and in those with cancer. Furthermore, adherence to DOACs appears to remain suboptimal. This narrative review aims to provide a practical guide for DOAC prescription and address challenging scenarios.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Fabrizio Oliva
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | | | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
| | - Iris Parrini
- Cardiology Department, Ospedale Mauriziano, 10128 Turin, Italy
| | - Maria Laura Canale
- Cardiology Department, Nuovo Ospedale Versilia Lido di Camaiore Lucca, 55049 Camaiore, Italy
| | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy
| | | | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy
| | - Giulio Binaghi
- Department of Cardiology, Azienda Ospedaliera Brotzu, 09047 Cagliari, Italy
| | - Alessandro Maloberti
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 88046 Lamezia, Italy
| | - Irma Bisceglia
- Integrated Cardiology Services, Department of Cardio-Thoracic-Vascular, Azienda Ospedaliera San Camillo Forlanini, 00152 Rome, Italy
| | - Roberta Rossini
- Cardiology Unit, Ospedale Santa Croce e Carle, 12100 Cuneo, Italy;
| | - Pier Luigi Temporelli
- Division of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, 28010 Gattico-Veruno, Italy
| | | | | | - Sandro Gelsomino
- Cardiovascular Research Institute, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
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Iribarren SJ, Milligan H, Chirico C, Goodwin K, Schnall R, Telles H, Iannizzotto A, Sanjurjo M, Lutz BR, Pike K, Rubinstein F, Rhodehamel M, Leon D, Keyes J, Demiris G. Patient-centered mobile tuberculosis treatment support tools (TB-TSTs) to improve treatment adherence: A pilot randomized controlled trial exploring feasibility, acceptability and refinement needs. LANCET REGIONAL HEALTH. AMERICAS 2022; 13:100291. [PMID: 36061038 PMCID: PMC9426680 DOI: 10.1016/j.lana.2022.100291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background Digital adherence technologies hold promise to improve patient-centered tuberculosis (TB) monitoring, yet few studies have incorporated direct adherence monitoring or assessed patients' experiences with these technologies. We explored acceptability, feasibility, and refinement needs of the TB Treatment Support Tools (TB-TSTs) intervention linking a mobile app, a urine drug metabolite test, and interactive communication with a treatment supporter. Methods This pilot study was a parallel-designed single-center randomized controlled trial with exit interviews. Newly diagnosed TB patients were randomized 1:1 using a treatment allocation button in the REDCap software preloaded with a random allocation sequence to usual care or usual care plus the TB-TSTs intervention from a respiratory medicine hospital in the province of Buenos Aires, Argentina and followed for 6-months. Due to the nature of the intervention, blinding to the group allocation could not be achieved for the recruiter or patients. The treatment outcome data extractor was blinded to the group allocation of the participants. Intervention participants used the app to report self-administering medication, potential side effects, submit photos of the urine test, and interact with a treatment supporter. Outcomes were feasibility, acceptability, and treatment outcomes. Findings Forty-two patients were enrolled and evenly assigned to each group. Intervention participants submitted 147·2±58 (mean, SD) medication self-administration and 144·5±55 side effect reports out of 180 and 47.5±38·4 photos of the urine test out of 77. Treatment success for usual care was 81% [17/21] and 95% [20/21] for the TB-TSTs intervention. Thirty-three themes were identified within the main categories of motivation, what worked, issues experienced, and recommendations. Participants (n=12) rated it as 'easy to use' (4.57/5), 'would highly recommend to others' (4·43/5) and reported that access to the treatment support was a critical component. Recommendations included adding an alarm, appointment reminders, and off-line functionality. Interpretation Findings suggest that the TB-TSTs intervention was feasible and acceptable and further refinement and testing is warranted. Funding National Institute of Health K23NR017210.
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Affiliation(s)
- Sarah J Iribarren
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
| | - Hannah Milligan
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
| | - Cristina Chirico
- Tuberculosis Control Program of the 5 Health Region, Ministry of Health of the Province of Buenos Aires, Hospital Cetrángolo, Buenos Aires, Argentina
| | - Kyle Goodwin
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
| | - Rebecca Schnall
- Columbia University School of Nursing, New York City, NY, USA
| | - Hugo Telles
- Tuberculosis Control Program of the 5 Health Region, Ministry of Health of the Province of Buenos Aires, Hospital Cetrángolo, Buenos Aires, Argentina
| | - Alejandra Iannizzotto
- Tuberculosis Control Program of the 5 Health Region, Ministry of Health of the Province of Buenos Aires, Hospital Cetrángolo, Buenos Aires, Argentina
| | - Myrian Sanjurjo
- Hospital del Tórax Dr. Antonio A. Cetrángolo, Provincia de Buenos Aires, Argentina
| | - Barry R Lutz
- Department of Bioengineering, University of Washington, Seattle, WA, USA
| | - Kenneth Pike
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
| | - Fernando Rubinstein
- Institute of Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Marcus Rhodehamel
- Department of Bioengineering, University of Washington, Seattle, WA, USA
| | - Daniel Leon
- Department of Bioengineering, University of Washington, Seattle, WA, USA
| | - Jesse Keyes
- Department of Bioengineering, University of Washington, Seattle, WA, USA
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Mason M, Cho Y, Rayo J, Gong Y, Harris M, Jiang Y. Technologies for Medication Adherence Monitoring and Technology Assessment Criteria: Narrative Review. JMIR Mhealth Uhealth 2022; 10:e35157. [PMID: 35266873 PMCID: PMC8949687 DOI: 10.2196/35157] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/23/2022] [Accepted: 01/28/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Accurate measurement and monitoring of patient medication adherence is a global challenge because of the absence of gold standard methods for adherence measurement. Recent attention has been directed toward the adoption of technologies for medication adherence monitoring, as they provide the opportunity for continuous tracking of individual medication adherence behavior. However, current medication adherence monitoring technologies vary according to their technical features and data capture methods, leading to differences in their respective advantages and limitations. Overall, appropriate criteria to guide the assessment of medication adherence monitoring technologies for optimal adoption and use are lacking. OBJECTIVE This study aims to provide a narrative review of current medication adherence monitoring technologies and propose a set of technology assessment criteria to support technology development and adoption. METHODS A literature search was conducted on PubMed, Scopus, CINAHL, and ProQuest Technology Collection (2010-present) using the combination of keywords medication adherence, measurement technology, and monitoring technology. The selection focused on studies related to medication adherence monitoring technology and its development and use. The technological features, data capture methods, and potential advantages and limitations of the identified technology applications were extracted. Methods for using data for adherence monitoring were also identified. Common recurring elements were synthesized as potential technology assessment criteria. RESULTS Of the 3865 articles retrieved, 98 (2.54%) were included in the final review, which reported a variety of technology applications for monitoring medication adherence, including electronic pill bottles or boxes, ingestible sensors, electronic medication management systems, blister pack technology, patient self-report technology, video-based technology, and motion sensor technology. Technical features varied by technology type, with common expectations for using these technologies to accurately monitor medication adherence and increase adoption in patients' daily lives owing to their unobtrusiveness and convenience of use. Most technologies were able to provide real-time monitoring of medication-taking behaviors but relied on proxy measures of medication adherence. Successful implementation of these technologies in clinical settings has rarely been reported. In all, 28 technology assessment criteria were identified and organized into the following five categories: development information, technology features, adherence to data collection and management, feasibility and implementation, and acceptability and usability. CONCLUSIONS This narrative review summarizes the technical features, data capture methods, and various advantages and limitations of medication adherence monitoring technology reported in the literature and the proposed criteria for assessing medication adherence monitoring technologies. This collection of assessment criteria can be a useful tool to guide the development and selection of relevant technologies, facilitating the optimal adoption and effective use of technology to improve medication adherence outcomes. Future studies are needed to further validate the medication adherence monitoring technology assessment criteria and construct an appropriate technology assessment framework.
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Affiliation(s)
- Madilyn Mason
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Youmin Cho
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Jessica Rayo
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Yang Gong
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Marcelline Harris
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Yun Jiang
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
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Tadesse AW, Mohammed Z, Foster N, Quaife M, McQuaid CF, Levy J, van Kalmthout K, van Rest J, Jerene D, Abdurhman T, Yazew H, Umeta DG, Assefa D, Weldemichael GT, Bedru A, Letta T, Fielding KL. Evaluation of implementation and effectiveness of digital adherence technology with differentiated care to support tuberculosis treatment adherence and improve treatment outcomes in Ethiopia: a study protocol for a cluster randomised trial. BMC Infect Dis 2021; 21:1149. [PMID: 34758737 PMCID: PMC8579414 DOI: 10.1186/s12879-021-06833-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 10/29/2021] [Indexed: 12/05/2022] Open
Abstract
Background Digital adherence technologies (DATs) are recommended to support patient-centred, differentiated care to improve tuberculosis (TB) treatment outcomes, but evidence that such technologies improve adherence is limited. We aim to implement and evaluate the effectiveness of smart pillboxes and medication labels linked to an adherence data platform, to create a differentiated care response to patient adherence and improve TB care among adult pulmonary TB participants. Our study is part of the Adherence Support Coalition to End TB (ASCENT) project in Ethiopia. Methods/Design We will conduct a pragmatic three-arm cluster-randomised trial with 78 health facilities in two regions in Ethiopia. Facilities are randomised (1:1:1) to either of the two intervention arms or standard of care. Adults aged ≥ 18 years with drug-sensitive (DS) pulmonary TB are enrolled over 12 months and followed-up for 12 months after treatment initiation. Participants in facilities randomised to either of the two intervention arms are offered a DAT linked to the web-based ASCENT adherence platform for daily adherence monitoring and differentiated response to patient adherence for those who have missed doses. Participants at standard of care facilities receive routine care. For those that had bacteriologically confirmed TB at treatment initiation and can produce sputum without induction, sputum culture will be performed approximately 6 months after the end of treatment to measure disease recurrence. The primary endpoint is a composite unfavourable outcome measured over 12 months from TB treatment initiation defined as either poor end of treatment outcome (lost to follow-up, death, or treatment failure) or treatment recurrence measured 6 months after the scheduled end of treatment. This study will also evaluate the effectiveness, feasibility, and cost-effectiveness of DAT systems for DS-TB patients. Discussion This trial will evaluate the impact and contextual factors of medication label and smart pillbox with a differentiated response to patient care, among adult pulmonary DS-TB participants in Ethiopia. If successful, this evaluation will generate valuable evidence via a shared evaluation framework for optimal use and scale-up. Trial registration: Pan African Clinical Trials Registry PACTR202008776694999, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12241, registered on August 11, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06833-x.
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Affiliation(s)
- Amare W Tadesse
- TB Centre, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine (LSHTM), London, UK.
| | | | - Nicola Foster
- TB Modelling Group, TB Centre, and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Matthew Quaife
- TB Modelling Group, TB Centre, and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Christopher Finn McQuaid
- TB Modelling Group, TB Centre, and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Jens Levy
- KNCV Tuberculosis Foundation, The Hague, the Netherlands
| | | | - Job van Rest
- KNCV Tuberculosis Foundation, The Hague, the Netherlands
| | - Degu Jerene
- KNCV Tuberculosis Foundation, The Hague, the Netherlands
| | | | - Hiwot Yazew
- KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | | | | | | | - Ahmed Bedru
- KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Taye Letta
- National Tuberculosis Control Program, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
| | - Katherine L Fielding
- TB Centre, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine (LSHTM), London, UK.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Davies B. 'Personal Health Surveillance': The Use of mHealth in Healthcare Responsibilisation. Public Health Ethics 2021; 14:268-280. [PMID: 34899983 PMCID: PMC8661076 DOI: 10.1093/phe/phab013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
There is an ongoing increase in the use of mobile health (mHealth) technologies that patients can use to monitor health-related outcomes and behaviours. While the dominant narrative around mHealth focuses on patient empowerment, there is potential for mHealth to fit into a growing push for patients to take personal responsibility for their health. I call the first of these uses 'medical monitoring', and the second 'personal health surveillance'. After outlining two problems which the use of mHealth might seem to enable us to overcome-fairness of burdens and reliance on self-reporting-I note that these problems would only really be solved by unacceptably comprehensive forms of personal health surveillance which applies to all of us at all times. A more plausible model is to use personal health surveillance as a last resort for patients who would otherwise independently qualify for responsibility-based penalties. However, I note that there are still a number of ethical and practical problems that such a policy would need to overcome. The prospects of mHealth enabling a fair, genuinely cost-saving policy of patient responsibility are slim.
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Affiliation(s)
- Ben Davies
- Uehiro Centre for Practical Ethics, University of Oxford
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10
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Sekandi JN, Kasiita V, Onuoha NA, Zalwango S, Nakkonde D, Kaawa-Mafigiri D, Turinawe J, Kakaire R, Davis-Olwell P, Atuyambe L, Buregyeya E. Stakeholders' Perceptions of Benefits of and Barriers to Using Video-Observed Treatment for Monitoring Patients With Tuberculosis in Uganda: Exploratory Qualitative Study. JMIR Mhealth Uhealth 2021; 9:e27131. [PMID: 34704961 PMCID: PMC8581755 DOI: 10.2196/27131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 08/15/2021] [Accepted: 09/07/2021] [Indexed: 01/19/2023] Open
Abstract
Background Nonadherence to treatment remains a barrier to tuberculosis (TB) control. Directly observed therapy (DOT) is the standard for monitoring adherence to TB treatment worldwide, but its implementation is challenging, especially in resource-limited settings. DOT is labor-intensive and inconvenient to both patients and health care workers. Video DOT (VDOT) is a novel patient-centered alternative that uses mobile technology to observe patients taking medication remotely. However, the perceptions and acceptability of potential end users have not been evaluated in Africa. Objective This study explores stakeholders’ acceptability of, as well as perceptions of potential benefits of and barriers to, using VDOT to inform a pilot study for monitoring patients with TB in urban Uganda. Methods An exploratory, qualitative, cross-sectional study with an exit survey was conducted in Kampala, Uganda, from April to May 2018. We conducted 5 focus group discussions, each comprising 6 participants. Groups included patients with TB (n=2 groups; male and female), health care providers (n=1), caregivers (n=1), and community DOT volunteer workers (n=1). The questions that captured perceived benefits and barriers were guided by domains adopted from the Technology Acceptance Model. These included perceived usefulness, ease of use, and intent to use technology. Eligible participants were aged ≥18 years and provided written informed consent. For patients with TB, we included only those who had completed at least 2 months of treatment to minimize the likelihood of infection. A purposive sample of patients, caregivers, health care providers, and community DOT workers was recruited at 4 TB clinics in Kampala. Trained interviewers conducted unstructured interviews that were audio-recorded, transcribed, and analyzed using inductive content analysis to generate emerging themes. Results The average age of participants was 34.5 (SD 10.7) years. VDOT was acceptable to most participants on a scale of 1 to 10. Of the participants, 70% (21/30) perceived it as highly acceptable, with scores ≥8, whereas 30% (9/30) scored between 5 and 7. Emergent themes on perceived benefits of VDOT were facilitation of easy adherence monitoring, timely follow-up on missed doses, patient-provider communication, and saving time and money because of minimal travel to meet in person. Perceived barriers included limited technology usability skills, inadequate cellular connectivity, internet access, availability of electricity, cost of the smartphone, and use of the internet. Some female patients raised concerns about the disruption of their domestic work routines to record videos. The impact of VDOT on privacy and confidentiality emerged as both a perceived benefit and barrier. Conclusions VDOT was acceptable and perceived as beneficial by most study participants, despite potential technical and cost barriers. Mixed perceptions emerged about the impact of VDOT on privacy and confidentiality. Future efforts should focus on training users, ensuring adequate technical infrastructure, assuring privacy, and performing comparative cost analyses in the local context.
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Affiliation(s)
- Juliet Nabbuye Sekandi
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States.,Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | | | - Nicole Amara Onuoha
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | - Sarah Zalwango
- School of Public Health, Makerere University, Kampala, Uganda.,Kampala Capital City Authority, Kampala, Uganda
| | | | | | - Julius Turinawe
- School of Public Health, Makerere University, Kampala, Uganda
| | - Robert Kakaire
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | - Paula Davis-Olwell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States.,Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | - Lynn Atuyambe
- School of Public Health, Makerere University, Kampala, Uganda
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11
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Iribarren S, Milligan H, Goodwin K, Aguilar Vidrio OA, Chirico C, Telles H, Morelli D, Lutz B, Sprecher J, Rubinstein F. Mobile Tuberculosis Treatment Support Tools to Increase Treatment Success in Patients with Tuberculosis in Argentina: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2021; 10:e28094. [PMID: 34152281 PMCID: PMC8277351 DOI: 10.2196/28094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/30/2021] [Accepted: 03/30/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) is an urgent global health threat and the world's deadliest infectious disease despite being largely curable. A critical challenge is to ensure that patients adhere to the full course of treatment to prevent the continued spread of the disease and development of drug-resistant disease. Mobile health interventions hold promise to provide the required adherence support to improve TB treatment outcomes. OBJECTIVE This study aims to evaluate the effectiveness of the TB treatment support tools (TB-TSTs) intervention on treatment outcomes (success and default) and to assess patient and provider perceptions of the facilitators and barriers to TB-TSTs implementation. METHODS The TB-TSTs study is an open-label, randomized controlled trial with 2 parallel groups in which 400 adult patients newly diagnosed with TB will be randomly assigned to receive usual care or usual care plus TB-TSTs. Participants will be recruited on a rolling basis from 4 clinical sites in Argentina. The intervention consists of a smartphone progressive web app, a treatment supporter (eg, TB nurse, physician, or social worker), and a direct adherence test strip engineered for home use. Intervention group participants will report treatment progress and interact with a treatment supporter using the app and metabolite urine test strip. The primary outcome will be treatment success. Secondary outcomes will include treatment default rates, self-reported adherence, technology use, and usability. We will assess patients' and providers' perceptions of barriers to implementation and synthesize lessons learned. We hypothesize that the TB-TSTs intervention will be more effective because it allows patients and TB supporters to monitor and address issues in real time and provide tailored support. We will share the results with stakeholders and policy makers. RESULTS Enrollment began in November 2020, with a delayed start due to the COVID-19 pandemic, and complete enrollment is expected by approximately July 2022. Data collection and follow-up are expected to be completed 6 months after the last patient is enrolled. Results from the analyses based on the primary end points are expected to be submitted for publication within a year of data collection completion. CONCLUSIONS To our knowledge, this randomized controlled trial will be the first study to evaluate a patient-centered remote treatment support strategy using a mobile tool and a home-based direct drug metabolite test. The results will provide robust scientific evidence on the effectiveness, implementation, and adoption of mobile health tools. The findings have broader implications not only for TB adherence but also more generally for chronic disease management and will improve our understanding of how to support patients facing challenging treatment regimens. TRIAL REGISTRATION ClinicalTrials.gov NCT04221789; https://clinicaltrials.gov/ct2/show/NCT04221789. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/28094.
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Affiliation(s)
- Sarah Iribarren
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, United States
| | - Hannah Milligan
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, United States
| | - Kyle Goodwin
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, United States
| | | | - Cristina Chirico
- National Tuberculosis Control Program, Region Five, Buenos Aires Argentina, Buenos Aires, Argentina
| | - Hugo Telles
- National Tuberculosis Control Program, Region Five, Buenos Aires Argentina, Buenos Aires, Argentina
| | - Daniela Morelli
- Institute of Clinical Effectiveness and Healthcare Policy, Buenos Aires, Argentina
| | - Barry Lutz
- Department of Bioengineering, University of Washington, Seattle, WA, United States
| | - Jennifer Sprecher
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, United States
| | - Fernando Rubinstein
- Institute of Clinical Effectiveness and Healthcare Policy, Buenos Aires, Argentina
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12
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Cortez AO, Melo ACD, Neves LDO, Resende KA, Camargos P. Tuberculosis in Brazil: one country, multiple realities. J Bras Pneumol 2021; 47:e20200119. [PMID: 33656156 PMCID: PMC8332839 DOI: 10.36416/1806-3756/e20200119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/01/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To identify the determinants of tuberculosis-related variables in the various regions of Brazil and evaluate trends in those variables over the ten-year period preceding the end of the timeframe defined for the United Nations Millennium Development Goals (MDGs). METHODS This was an ecological analytical study in which we utilized eight national public databases to investigate the 716,971 new tuberculosis cases reported between 2006 and 2015. RESULTS Over the study period, there were slight reductions in the prevalence, incidence, and mortality associated with tuberculosis. Brazil did not reach the MDG for tuberculosis-related mortality. Among the performance indicators of tuberculosis control, there were improvements only in those related to treatment and treatment abandonment. In terms of the magnitude of tuberculosis, substantial regional differences were observed. The tuberculosis incidence rate was highest in the northern region, as were the annual mean temperature and relative air humidity. That region also had the second lowest human development index, primary health care (PHC) coverage, and number of hospitalizations for tuberculosis. The northeastern region had the highest PHC coverage, number of hospitalizations for primary care-sensitive conditions, and tuberculosis-related mortality rate. The southern region showed the smallest reductions in epidemiological indicators, together with the greatest increases in the frequency of treatment abandonment and retreatment. The central-west region showed the lowest overall magnitude of tuberculosis and better monitoring indicators. CONCLUSIONS The situation related to tuberculosis differs among the five regions of Brazil. Those differences can make it difficult to control the disease in the country and could explain the fact that Brazil failed to reach the MDG for tuberculosis-related mortality. Tuberculosis control measures should be adapted to account for regional differences.
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Affiliation(s)
- Andreza Oliveira Cortez
- . Programa de Pós-Graduação em Ciências da Saúde, Grupo de Pesquisa em Tuberculose e Doenças Infecciosas, Universidade Federal de São João del-Rei, Divinópolis (MG) Brasil
| | - Angelita Cristine de Melo
- . Programa de Pós-Graduação em Ciências da Saúde, Grupo de Pesquisa em Tuberculose e Doenças Infecciosas, Universidade Federal de São João del-Rei, Divinópolis (MG) Brasil.,. Programa de Pós-Graduação em Ciências Farmacêuticas, Grupo de Pesquisa em Farmácia Clínica, Assistência Farmacêutica e Saúde Coletiva, Universidade Federal de São João del-Rei, Divinópolis (MG) Brasil
| | - Leonardo de Oliveira Neves
- . Grupo de Pesquisa em Micrometeorologia de Ecossistemas, Instituto Federal Catarinense, Rio do Sul (SC) Brasil
| | - Karina Aparecida Resende
- . Programa de Pós-Graduação em Ciências Farmacêuticas, Grupo de Pesquisa em Farmácia Clínica, Assistência Farmacêutica e Saúde Coletiva, Universidade Federal de São João del-Rei, Divinópolis (MG) Brasil
| | - Paulo Camargos
- . Programa de Pós-Graduação em Ciências da Saúde, Grupo de Pesquisa em Tuberculose e Doenças Infecciosas, Universidade Federal de São João del-Rei, Divinópolis (MG) Brasil
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13
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Milligan H, Iribarren SJ, Chirico C, Telles H, Schnall R. Insights from participant engagement with the tuberculosis treatment support tools intervention: Thematic analysis of interactive messages to guide refinement to better meet end user needs. Int J Med Inform 2021; 149:104421. [PMID: 33706032 DOI: 10.1016/j.ijmedinf.2021.104421] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/10/2021] [Accepted: 02/15/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Tuberculosis (TB) is a largely curable disease, yet it remains one of the top ten causes of death globally. In response to known challenges to completing the long course of TB treatment, our study team developed the TB treatment support tools (TB-TSTs). The mobile application (app) is comprised of the following main components: 1) tracks treatment progress, 2) provides disease tailored information, 3) interactive communication between patients and treatment supporters, and 4) is linked with a direct adherence drug metabolite test. OBJECTIVE The objective of this study was to analyze the interactive communication between the patients and the treatment supporter during the TB-TSTs pilot testing to identify issues and guide intervention refinement. METHODS We used mixed methods to analyze the interactive communication data. The study was conducted at a pulmonary disease specialized hospital in Argentina. Of the 42 study participants enrolled in the pilot study, 21 were randomly assigned to use the TB-TSTs for 6-months during their TB treatment. The treatment supporter was a registered nurse from the regional level of the National TB program. We conducted thematic and content analysis of the messages in their original language, Spanish. We assessed the themes over time and by whom initiated the messages. RESULTS There were 2561 individual messages sent between the participants and treatment supporter. We identified 19 main themes: 7 were participant and 12 were treatment supporter initiated. Participant themes included missed report rationale, arranging in-person meeting, intervention support, TB treatment progress, disease/treatment questions, side effects and additional support. Treatment supporter themes included missed report inquiry, arranging in-person meeting, introduction and instructions, check-in's, positive reinforcement, treatment progress inquiry, test-strip issues, intervention orientation, initial side-effect check in, follow-up on side effects and photo quality issues. Messages and themes decreased over time with most occurring within the first 2 months of treatment. CONCLUSIONS Although there was a decrease in the number of messages and the theme types over the 6-month study participation, treatment adherence support remained needed throughout. Potential solutions are suggested for the main issues and recommendations are being used to guide refinement.
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Affiliation(s)
- Hannah Milligan
- Department of Bio-behavioral Nursing and Health Informatics, University of Washington, Seattle, WA, United States.
| | - Sarah J Iribarren
- Department of Bio-behavioral Nursing and Health Informatics, University of Washington, Seattle, WA, United States.
| | - Cristina Chirico
- National Tuberculosis Control Program Region Five (Programa Control de la Tuberculosis Región Sanitaria V.), Hospital Zonal Del Torax Dr Antonio Cetrangolo, Buenos Aires, Argentina
| | - Hugo Telles
- National Tuberculosis Control Program Region Five (Programa Control de la Tuberculosis Región Sanitaria V.), Hospital Zonal Del Torax Dr Antonio Cetrangolo, Buenos Aires, Argentina
| | - Rebecca Schnall
- Columbia University School of Nursing, New York, NY, United States
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14
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Sekandi JN, Onuoha NA, Buregyeya E, Zalwango S, Kaggwa PE, Nakkonde D, Kakaire R, Atuyambe L, Whalen CC, Dobbin KK. Using a Mobile Health Intervention (DOT Selfie) With Transfer of Social Bundle Incentives to Increase Treatment Adherence in Tuberculosis Patients in Uganda: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2021; 10:e18029. [PMID: 32990629 PMCID: PMC7815451 DOI: 10.2196/18029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/10/2020] [Accepted: 09/16/2020] [Indexed: 12/13/2022] Open
Abstract
Background The World Health Organization’s End TB Strategy envisions a world free of tuberculosis (TB)—free of deaths, disease, and suffering due to TB—by 2035. Nonadherence reduces cure rates, prolongs infectiousness, and contributes to the emergence of multidrug-resistant TB (MDR-TB). Moreover, MDR-TB is a growing, complex, and costly problem that presents a major obstacle to TB control. Directly observed therapy (DOT) for treatment adherence monitoring is the recommended standard; however, it is challenging to implement at scale because it is labor-intensive. Mobile health interventions can facilitate remote adherence monitoring and minimize the costs and inconveniences associated with standard DOT. Objective The study aims to evaluate the effectiveness of using video directly observed therapy (VDOT) plus incentives to improve medication adherence in TB treatment versus usual-care DOT in an African context. Methods The DOT Selfie study is an open-label, randomized controlled trial (RCT) with 2 parallel groups, in which 144 adult patients with TB aged 18-65 years will be randomly assigned to receive the usual-care DOT monitoring or VDOT as the intervention. The intervention will consist of a smartphone app, a weekly internet subscription, translated text message reminders, and incentives for those who adhere. The participant will use a smartphone to record and send time-stamped encrypted videos showing their daily medication ingestion. This video component will directly substitute the need for daily face-to-face meetings between the health provider and patients. We hypothesize that the VDOT intervention will be more effective because it allows patients to swallow their pills anywhere, anytime. Moreover, patients will receive mobile-phone–based “social bundle” incentives to motivate adherence to continued daily submission of videos to the health system. The health providers will log into a secured computer system to verify treatment adherence, document missed doses, investigate the reasons for missed doses, and follow prespecified protocol measures to re-establish medication adherence. The primary endpoint is the adherence level as measured by the fraction of expected doses observed over the treatment period. The main secondary outcome will be time-to-treatment completion in both groups. Results This study was funded in 2019. Enrollment began in July and is expected to be completed by November 2020. Data collection and follow-up are expected to be completed by June 2021. Results from the analyses based on the primary endpoint are expected to be submitted for publication by December 2021. Conclusions This random control trial will be among the first to evaluate the effectiveness of VDOT within an African setting. The results will provide robust scientific evidence on the implementation and adoption of mobile health (mHealth) tools, coupled with incentives to motivate TB medication adherence. If successful, VDOT will apply to other low-income settings and a range of chronic diseases with lifelong treatment, such as HIV/AIDs. Trial Registration ClinicalTrials.gov NCT04134689; http://clinicaltrials.gov/ct2/show/NCT04134689 International Registered Report Identifier (IRRID) DERR1-10.2196/18029
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Affiliation(s)
- Juliet Nabbuye Sekandi
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States.,Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States
| | - Nicole Amara Onuoha
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | | | - Sarah Zalwango
- School of Public Health, Makerere University, Kampala, Uganda.,Department of Public Health Service and Environment, Kampala Capital City Authority, Kampala, Uganda
| | | | | | - Robert Kakaire
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | - Lynn Atuyambe
- School of Public Health, Makerere University, Kampala, Uganda
| | - Christopher C Whalen
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States.,Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States
| | - Kevin K Dobbin
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States
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15
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Morse RM, Myburgh H, Reubi D, Archey AE, Busakwe L, Garcia-Prats AJ, Hesseling AC, Jacobs S, Mbaba S, Meyerson K, Seddon JA, van der Zalm MM, Wademan DT, Hoddinott G. Opportunities for Mobile App-Based Adherence Support for Children With Tuberculosis in South Africa. JMIR Mhealth Uhealth 2020; 8:e19154. [PMID: 33174850 PMCID: PMC7688382 DOI: 10.2196/19154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/03/2020] [Accepted: 09/07/2020] [Indexed: 01/20/2023] Open
Abstract
Tuberculosis is the number one infectious cause of death globally. Young children, generally those younger than 5 years, are at the highest risk of progressing from tuberculosis infection to tuberculosis disease and of developing the most severe forms of tuberculosis. Most current tuberculosis drug formulations have poor acceptability among children and require consistent adherence for prolonged periods of time. These challenges complicate children’s adherence to treatment and caregivers’ daily administration of the drugs. Rapid developments in mobile technologies and apps present opportunities for using widely available technology to support national tuberculosis programs and patient treatment adherence. Pilot studies have demonstrated that mobile apps are a feasible and acceptable means of enhancing children’s treatment adherence for other chronic conditions. Despite this, no mobile apps that aim to promote adherence to tuberculosis treatment have been developed for children. In this paper, we draw on our experiences carrying out research in clinical pediatric tuberculosis studies in South Africa. We present hypothetical scenarios of children’s adherence to tuberculosis medication to suggest priorities for behavioral and educational strategies that a mobile app could incorporate to address some of the adherence support gaps faced by children diagnosed with tuberculosis. We argue that a mobile app has the potential to lessen some of the negative experiences that children associate with taking tuberculosis treatment and to facilitate a more positive treatment adherence experience for children and their caregivers.
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Affiliation(s)
- Rachel M Morse
- Department of Global Health and Social Medicine, King's College London, London, United Kingdom
| | - Hanlie Myburgh
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | - David Reubi
- Department of Global Health and Social Medicine, King's College London, London, United Kingdom
| | - Ava E Archey
- College of Arts and Sciences, University of Virginia, Charlottesville, VA, United States
| | - Leletu Busakwe
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Social Aspects of Public Health, Human Sciences Research Council, Cape Town, South Africa
| | - Anthony J Garcia-Prats
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anneke C Hesseling
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stephanie Jacobs
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sharon Mbaba
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kyla Meyerson
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - James A Seddon
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Marieke M van der Zalm
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Dillon T Wademan
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Graeme Hoddinott
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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16
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Manyazewal T, Woldeamanuel Y, Holland DP, Fekadu A, Blumberg HM, Marconi VC. Electronic pillbox-enabled self-administered therapy versus standard directly observed therapy for tuberculosis medication adherence and treatment outcomes in Ethiopia (SELFTB): protocol for a multicenter randomized controlled trial. Trials 2020; 21:383. [PMID: 32370774 PMCID: PMC7201596 DOI: 10.1186/s13063-020-04324-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/10/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To address the multifaceted challenges associated with tuberculosis (TB) in-person directly observed therapy (DOT), the World Health Organization recently recommended that countries maximize the use of digital adherence technologies. Sub-Saharan Africa needs to investigate the effectiveness of such technologies in local contexts and proactively contribute to global decisions around patient-centered TB care. This study aims to evaluate the effectiveness of pillbox-enabled self-administered therapy (SAT) compared to standard DOT on adherence to TB medication and treatment outcomes in Ethiopia. It also aims to assess the usability, acceptability, and cost-effectiveness of the intervention from the patient and provider perspectives. METHODS This is a multicenter, randomized, controlled, open-label, superiority, effectiveness-implementation hybrid, mixed-methods, two-arm trial. The study is designed to enroll 144 outpatients with new or previously treated, bacteriologically confirmed, drug-sensitive pulmonary TB who are eligible to start the standard 6-month first-line anti-TB regimen. Participants in the intervention arm (n = 72) will receive 15 days of HRZE-isoniazid, rifampicin, pyrazinamide, and ethambutol-fixed-dose combination therapy in the evriMED500 medication event reminder monitor device for self-administration. When returned, providers will count any remaining tablets in the device, download the pill-taking data, and refill based on preset criteria. Participants can consult the provider in cases of illness or adverse events outside of scheduled visits. Providers will handle participants in the control arm (n = 72) according to the standard in-person DOT. Both arms will be followed up throughout the 2-month intensive phase. The primary outcomes will be medication adherence and sputum conversion. Adherence to medication will be calculated as the proportion of patients who missed doses in the intervention (pill count) versus DOT (direct observation) arms, confirmed further by IsoScreen urine isoniazid test and a self-report of adherence on eight-item Morisky Medication Adherence Scale. Sputum conversion is defined as the proportion of patients with smear conversion following the intensive phase in intervention versus DOT arms, confirmed further by pre-post intensive phase BACTEC MGIT TB liquid culture. Pre-post treatment MGIT drug susceptibility testing will determine whether resistance to anti-TB drugs could have impacted culture conversion. Secondary outcomes will include other clinical outcomes (treatment not completed, death, or loss to follow-up), cost-effectiveness-individual and societal costs with quality-adjusted life years-and acceptability and usability of the intervention by patients and providers. DISCUSSION This study will be the first in Ethiopia, and of the first three in sub-Saharan Africa, to determine whether electronic pillbox-enabled SAT improves adherence to TB medication and treatment outcomes, all without affecting the inherent dignity and economic wellbeing of patients with TB. TRIAL REGISTRATION ClinicalTrials.gov, NCT04216420. Registered on 2 January 2020.
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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, P.O. Box 9086, Addis Ababa, Ethiopia
| | - Yimtubezinash Woldeamanuel
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa, P.O. Box 9086, Addis Ababa, Ethiopia
| | - David P. Holland
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA 30322 USA
| | - Abebaw Fekadu
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa, P.O. Box 9086, Addis Ababa, Ethiopia
| | - Henry M. Blumberg
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA 30322 USA
| | - Vincent C. Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA 30322 USA
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17
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Sekandi JN, Buregyeya E, Zalwango S, Dobbin KK, Atuyambe L, Nakkonde D, Turinawe J, Tucker EG, Olowookere S, Turyahabwe S, Garfein RS. Video directly observed therapy for supporting and monitoring adherence to tuberculosis treatment in Uganda: a pilot cohort study. ERJ Open Res 2020; 6:00175-2019. [PMID: 32280670 PMCID: PMC7132038 DOI: 10.1183/23120541.00175-2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 02/11/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Nonadherence to treatment remains an obstacle to tuberculosis (TB) control worldwide. The aim of this study was to evaluate the feasibility of using video directly observed therapy (VDOT) for supporting TB treatment adherence in Uganda. Methods From May to December 2018, we conducted a pilot cohort study at a TB clinic in Kampala City. We enrolled patients aged 18–65 years with ≥3 months remaining of their TB treatment. Participants were trained to use a smartphone app to record videos of medication intake and submit them to a secured system. Trained health workers logged into the system to watch the submitted videos. The primary outcome was adherence measured as the fraction of expected doses observed (FEDO). In a secondary analysis, we examined differences in FEDO by sex, age, phone ownership, duration of follow-up, reasons for missed videos and patients' satisfaction at study exit. Results Of 52 patients enrolled, 50 were analysed. 28 (56%) were male, the mean age was 31 years (range 19–50 years) and 35 (70%) owned smartphones. Of the 5150 videos expected, 4231 (82.2%) were received. The median FEDO was 85% (interquartile range 66%–94%) and this significantly differed by follow-up duration. Phone malfunction, uncharged battery and VDOT app malfunctions were the commonest reasons for missed videos. 92% of patients reported being very satisfied with using VDOT. Conclusion VDOT was feasible and acceptable for monitoring and supporting TB treatment. It resulted in high levels of adherence, suggesting that digital technology holds promise in improving patient monitoring in Uganda. Video directly observed therapy is feasible and acceptable for supporting and monitoring TB treatment adherence in a low-resource setting like Uganda. Digital health interventions hold promise as alternative methods for improving patient care.http://bit.ly/2Hxnvwu
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Affiliation(s)
- Juliet N Sekandi
- Dept of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA.,Global Health Institute, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Sarah Zalwango
- School of Public Health, Makerere University, Kampala, Uganda.,Kampala Capital City Authority, Dept of Public Health Service and Environment, Kampala, Uganda
| | - Kevin K Dobbin
- Dept of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Lynn Atuyambe
- School of Public Health, Makerere University, Kampala, Uganda
| | | | - Julius Turinawe
- School of Public Health, Makerere University, Kampala, Uganda
| | - Emma G Tucker
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, USA
| | - Shade Olowookere
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Richard S Garfein
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
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Lee Y, Raviglione MC, Flahault A. Use of Digital Technology to Enhance Tuberculosis Control: Scoping Review. J Med Internet Res 2020; 22:e15727. [PMID: 32053111 PMCID: PMC7055857 DOI: 10.2196/15727] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 02/06/2023] Open
Abstract
Background Tuberculosis (TB) is the leading cause of death from a single infectious agent, with around 1.5 million deaths reported in 2018, and is a major contributor to suffering worldwide, with an estimated 10 million new cases every year. In the context of the World Health Organization’s End TB strategy and the quest for digital innovations, there is a need to understand what is happening around the world regarding research into the use of digital technology for better TB care and control. Objective The purpose of this scoping review was to summarize the state of research on the use of digital technology to enhance TB care and control. This study provides an overview of publications covering this subject and answers 3 main questions: (1) to what extent has the issue been addressed in the scientific literature between January 2016 and March 2019, (2) which countries have been investing in research in this field, and (3) what digital technologies were used? Methods A Web-based search was conducted on PubMed and Web of Science. Studies that describe the use of digital technology with specific reference to keywords such as TB, digital health, eHealth, and mHealth were included. Data from selected studies were synthesized into 4 functions using narrative and graphical methods. Such digital health interventions were categorized based on 2 classifications, one by function and the other by targeted user. Results A total of 145 relevant studies were identified out of the 1005 published between January 2016 and March 2019. Overall, 72.4% (105/145) of the research focused on patient care and 20.7% (30/145) on surveillance and monitoring. Other programmatic functions 4.8% (7/145) and electronic learning 2.1% (3/145) were less frequently studied. Most digital health technologies used for patient care included primarily diagnostic 59.4% (63/106) and treatment adherence tools 40.6% (43/106). On the basis of the second type of classification, 107 studies targeted health care providers (107/145, 73.8%), 20 studies targeted clients (20/145, 13.8%), 17 dealt with data services (17/145, 11.7%), and 1 study was on the health system or resource management. The first authors’ affiliations were mainly from 3 countries: the United States (30/145 studies, 20.7%), China (20/145 studies, 13.8%), and India (17/145 studies, 11.7%). The researchers from the United States conducted their research both domestically and abroad, whereas researchers from China and India conducted all studies domestically. Conclusions The majority of research conducted between January 2016 and March 2019 on digital interventions for TB focused on diagnostic tools and treatment adherence technologies, such as video-observed therapy and SMS. Only a few studies addressed interventions for data services and health system or resource management.
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Affiliation(s)
- Yejin Lee
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Mario C Raviglione
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland.,Centre for Multidisciplinary Research in Health Science (MACH), Università di Milano, Milan, Italy
| | - Antoine Flahault
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland
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Jo Y, Mirzoeva F, Chry M, Qin ZZ, Codlin A, Bobokhojaev O, Creswell J, Sohn H. Standardized framework for evaluating costs of active case-finding programs: An analysis of two programs in Cambodia and Tajikistan. PLoS One 2020; 15:e0228216. [PMID: 31986183 PMCID: PMC6984737 DOI: 10.1371/journal.pone.0228216] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/09/2020] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Over the years, technological and process innovations enabled active case finding (ACF) programs to expand their capacities and scope to have evolved to close gaps in missing TB patients globally. However, with increased ACF program's operational complexity and a need for significant resource commitments, a comprehensive, transparent, and standardized approach in evaluating costs of ACF programs is needed to properly determine costs and value of ACF programs. METHODS Based on reviews of program activity and financial reports, multiple interviews with program managers of two TB REACH funded ACF programs deployed in Cambodia and Tajikistan, we first identified common program components, which formed the basis of the cost data collection, analysis, reporting framework. Within each program component and sub-activity group, cost data were collected and organized by relevant resource types (human resource, capital, recurrent, and overhead costs). Total shared, indirect and overhead costs were apportioned into each activity category based on direct human resource contribution (e.g. a number of staff and their relative level of effort dedicated to each program component). Capital assets were assessed specific to program components and were annualized based on their expected useful life and a 3% discount rate. All costs were assessed based on the service provider perspective and expressed in 2015 USD. RESULTS Over the two program years (April 2013 to December 2015), the Cambodia and Tajikistan ACF programs cumulated a total cost of $336,951 and $771,429 to screen 68,846 and 1,980,516 target population, bacteriologically test 4,589 and 19,764 presumptive TB, diagnose 731 and 2,246 TB patients in the respective programs. Recurrent costs were the largest cost components (54% and 34%) of the total costs for the respective programs and Xpert MTB/RIF (Xpert) testing incurred largest program component/activity cost for both programs. Cost per screening was $0.63 and $0.10 and cost per Xpert test was $25 and $18; Cost per TB case detected (Xpert) was $373 and $343 in Cambodia and Tajikistan. CONCLUSIONS Results from two contextually and programmatically different multi-component ACF programs demonstrate that our tool is fully capable of comprehensively and transparently evaluating and comparing costs of various ACF programs.
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Affiliation(s)
- Youngji Jo
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Farangiz Mirzoeva
- Republican Centre of Population Protection from Tuberculosis, Dushanbe, Tajikistan
| | - Monyrath Chry
- Cambodia Anti-Tuberculosis Association, Phnom Penh, Cambodia
| | | | | | - Oktam Bobokhojaev
- Republican Centre of Population Protection from Tuberculosis, Dushanbe, Tajikistan
| | - Jacob Creswell
- Cambodia Anti-Tuberculosis Association, Phnom Penh, Cambodia
| | - Hojoon Sohn
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- * E-mail:
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20
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Iribarren SJ, Rodriguez Y, Lin L, Chirico C, Discacciati V, Schnall R, Demiris G. Converting and expanding a mobile support intervention: Focus group and field-testing findings from individuals in active tuberculosis treatment. Int J Med Inform 2020; 136:104057. [PMID: 31981744 DOI: 10.1016/j.ijmedinf.2019.104057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/17/2019] [Accepted: 12/17/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Non-adherence to tuberculosis (TB) treatment jeopardizes the individual's health and contributes to disease transmission and drug resistance. New patient-centered strategies are needed to improve TB treatment outcomes. PURPOSE To convert and expand a texting-based intervention into a mobile optimized application (app), evaluate the feasibility of an added self-administered paper-based drug metabolite test, and identify needs and preferences to inform their iterative design. METHODS Qualitative methods using focus groups and field testing with patients in active TB treatment were used to gather initial input on the converted intervention design, content and issues using at home test strips to report medication adherence. Seven participants were recruited from an outpatient clinic within a regional public reference hospital specialized in respiratory diseases in Argentina. Thematic analyses were conducted on the transcripts and session notes. RESULTS Participants considered interactive communication, access to answers to frequently asked questions, and tracking of progress in treatment as important. Participants reported having many questions and uncertainties at initiation of treatment and emphasized a need for reliable information, assurance and support from both providers and peers. Other suggestions included streamlining the graphical user interface for easier and shorter data entry times and usability. CONCLUSIONS Overall feedback from the participants regarding the intervention was positive, reporting that it was useful and relevant, and they were eager to contribute their ideas for improvement and additional functionality. Valuable feedback to improve functionality and meet the needs of end-users were obtained to inform the generation of new design ideas for refinement and testing in a pilot study.
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Affiliation(s)
- Sarah J Iribarren
- Biobehavioral Nursing and Health Informatics, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
| | - Yvette Rodriguez
- University of Washington, School of Nursing, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
| | - Lorelei Lin
- University of Washington, School of Nursing, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
| | - Cristina Chirico
- Tuberculosis Control Program of the 5th Health Region, Ministry of Health of the Province of Buenos Aires, Hospital Cetrangolo, Buenos Aires, Argentina.
| | - Vilda Discacciati
- Division of Family and Community Medicine, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH Buenos Aires, Argentina.
| | - Rebecca Schnall
- Columbia University, School of Nursing, Columbia University, New York, NY, USA.
| | - George Demiris
- University of Pennsylvania, School of Nursing, Claire Fagin Hall, Rm 324, 418 Curie Blvd, Philadelphia PA, 19104, USA.
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21
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Garfein RS, Doshi RP. Synchronous and asynchronous video observed therapy (VOT) for tuberculosis treatment adherence monitoring and support. J Clin Tuberc Other Mycobact Dis 2019; 17:100098. [PMID: 31867442 PMCID: PMC6904830 DOI: 10.1016/j.jctube.2019.100098] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Directly observed therapy (DOT) for monitoring tuberculosis (TB) treatment is intended to reduce disease transmission, mortality and acquired drug resistance by facilitating treatment adherence and support. Synchronous (S-VOT) and asynchronous (A-VOT) video observed therapy are mHealth solutions for remotely monitoring medication ingestion. This paper synthesizes literature through December 2018 to describe existing VOT approaches, summarize evidence, identify knowledge gaps, evaluate VOT strengths and weaknesses, and examine patient and provider factors influencing VOT feasibility and acceptability. High rates of adherence and patient acceptance were obtained using both VOT methods. VOT reduced travel time for TB program staff and/or patients, improving program efficiency compared to in-person DOT while maintaining high patient satisfaction. The impact of VOT on TB treatment outcomes, such as cure and relapse, require further study with longer follow-up. Individual patient, provider and program factors should be considered in selecting either or both VOT approaches for provision of patient-centered care.
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Affiliation(s)
- Richard S. Garfein
- Division of Epidemiology, School of Medicine, University of California San Diego, 9500 Gilman Drive, Mailcode-0725, La Jolla, CA 92093-0725, USA
| | - Riddhi P. Doshi
- Division of Behavioral Sciences and Community Health, School of Dental Medicine, University of Connecticut Health Center, 263 Farmington Avenue, MC 6030, Farmington, CT 06030, USA
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22
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Maher NA, Senders JT, Hulsbergen AF, Lamba N, Parker M, Onnela JP, Bredenoord AL, Smith TR, Broekman ML. Passive data collection and use in healthcare: A systematic review of ethical issues. Int J Med Inform 2019; 129:242-247. [DOI: 10.1016/j.ijmedinf.2019.06.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/15/2019] [Accepted: 06/17/2019] [Indexed: 12/17/2022]
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23
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Mahomed S, Padayatchi N, Singh J, Naidoo K. Precision medicine in resistant Tuberculosis: Treat the correct patient, at the correct time, with the correct drug. J Infect 2019; 78:261-268. [PMID: 30849440 DOI: 10.1016/j.jinf.2019.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/01/2019] [Accepted: 03/03/2019] [Indexed: 01/30/2023]
Abstract
Human genomic mapping has advanced molecular medicine health care and created a transformative paradigm shift towards Precision Medicine. In 2015, President Obama launched the PM initiative, encapsulated as "unique individualized data-driven treatments". Since then, this field is rapidly advancing both curative treatment and disease prevention by accounting for both individual and environmental variability. While a substantial evidence for accelerating adoption of Precision Medicine in other spheres of medicine exists, application of Precision Medicine in infectious diseases is far more complex. One of the most warranted applications of precision healthcare is in the management and treatment of Drug-resistant Tuberculosis. Application of Precision Medicine to Drug-resistant Tuberculosis could potentially change the landscape of treatment and prevention of a disease affecting vulnerable patients in impoverished communities. Poorly diagnosed and treated Drug-resistant Tuberculosis not only leads to increased mortality and morbidity but also increased transmission of DR-TB strains, fuelling ongoing high incidence rates and further infection. A Precision medicine model using individual clinical case histories used in conjunction with Mycobacterium Tuberculosis infection genomic data will better guide health care practitioners in more appropriate drug selection, and an individualized management approach. This viewpoint deliberates the intricacies of adopting a PM approach in the management of DR-TB. If applied correctly, we postulate that the research, application, and deployment of PM in DR-TB management may address the fundamental rule of PM in infectious disease: to treat the correct patient, at the correct time, with the correct drug.
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Affiliation(s)
- Sharana Mahomed
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, Durban, South Africa.
| | - Nesri Padayatchi
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, Durban, South Africa.
| | - Jerome Singh
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, Durban, South Africa.
| | - Kogieleum Naidoo
- CAPRISA, Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, Durban, South Africa.
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Ali J, DiStefano MJ, Coates McCall I, Gibson DG, Al Kibria GM, Pariyo GW, Labrique AB, Hyder AA. Ethics of mobile phone surveys to monitor non-communicable disease risk factors in low- and middle-income countries: A global stakeholder survey. Glob Public Health 2019; 14:1167-1181. [PMID: 30628548 DOI: 10.1080/17441692.2019.1566482] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Active public health surveillance has traditionally been carried out through face-to-face household surveys or contact with providers, which can be time and resource intensive. The increasing ubiquity of mobile phones and availability of phone survey platforms provide an opportunity to explore the use of mobile phone surveys (MPS) for active disease and risk factor surveillance, including for non-communicable diseases (NCDs). Scholars are increasingly examining the ethics implications of mobile health (mHealth), but few have focused on the ethics of mHealth in low- and middle-income countries (LMICs), and even fewer on mHealth for active surveillance. Given that little is known about ethics-related attitudes and practices of stakeholders invested in the conduct and oversight of mHealth in LMICs, we undertook a cross-sectional global stakeholder survey of ethics-related issues implicated by active observational MPS, with a contextual frame of monitoring NCD risk factors in LMICs. We analyse these findings with an organising focus on ethical issues that arise before, during and after conduct of an MPS including defining the activity; anticipating harms and benefits; obtaining consent; data ownership, access, and use; and ensuring sustainability. Finally, we present a set of empirical, conceptual, and normative considerations that arise from this analysis and merit further consideration.
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Affiliation(s)
- Joseph Ali
- a Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University , Baltimore , MD , USA.,b Berman Institute of Bioethics, Johns Hopkins University , Baltimore , MD , USA
| | - Michael J DiStefano
- a Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University , Baltimore , MD , USA.,b Berman Institute of Bioethics, Johns Hopkins University , Baltimore , MD , USA
| | - Iris Coates McCall
- b Berman Institute of Bioethics, Johns Hopkins University , Baltimore , MD , USA
| | - Dustin G Gibson
- a Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University , Baltimore , MD , USA
| | | | - George W Pariyo
- a Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University , Baltimore , MD , USA
| | - Alain B Labrique
- a Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University , Baltimore , MD , USA
| | - Adnan A Hyder
- d Milken Institute School of Public Health, The George Washington University , Washington , DC , USA
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Fang XH, Dan YL, Liu J, Jun L, Zhang ZP, Kan XH, Ma DC, Wu GC. Factors influencing completion of treatment among pulmonary tuberculosis patients. Patient Prefer Adherence 2019; 13:491-496. [PMID: 31114167 PMCID: PMC6497847 DOI: 10.2147/ppa.s198007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 03/12/2019] [Indexed: 12/20/2022] Open
Abstract
Objective: This study aimed to understand the influencing factors of treatment completion among pulmonary tuberculosis (PTB) patients in Anhui province, eastern People's Republic of China, in order to provide scientific evidence for improving the follow-up rate and treatment completion rate. Methods: A total of 262 PTB patients in six counties (districts) of Anhui province were investigated by questionnaire, and data about treatment interruption were collected. Results: The main causes of treatment interruption were forgetting to take medicine (24.5%), drug side effects (23.3%), and symptomatic improvement (19.5%). The education background, patient type, cause of interruption, and tracking method were factors influencing completion of treatment (all P<0.05). The education level was positively associated with the treatment completion rate. New smear-positive patients had a significantly higher completion rate than others. The patients interrupted by drug side effects had the highest risk of interruption. In terms of the tracking method, the completion rate of patients tracked by the rural medical staff was significantly lower. Conclusions: The management of PTB patients by medication supervision should be strengthened, especially for those with low education level and who had drug side effects, in order to improve their treatment completion rate.
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Affiliation(s)
- Xue-Hui Fang
- Department of Science and Education, Anhui Provincial TB Institute, Hefei, Anhui, People’s Republic of China
| | - Yi-Lin Dan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, People’s Republic of China
| | - Jie Liu
- Department of Science and Education, Anhui Provincial TB Institute, Hefei, Anhui, People’s Republic of China
| | - Lei Jun
- Department of Science and Education, Anhui Provincial TB Institute, Hefei, Anhui, People’s Republic of China
| | - Zhi-Ping Zhang
- Department of Tuberculosis Prevention, Anqing Center for Disease Control and Prevention, Anqing, Anhui, People’s Republic of China
| | - Xiao-Hong Kan
- Department of Science and Education, Anhui Provincial TB Institute, Hefei, Anhui, People’s Republic of China
| | - Dong-Chun Ma
- Department of Science and Education, Anhui Provincial TB Institute, Hefei, Anhui, People’s Republic of China
- Correspondence: Dong-Chun MaDepartment of Science and Education, Anhui Provincial TB Institute, Hefei, Anhui, 230022, People’s Republic of ChinaEmail
| | - Guo-Cui Wu
- School of Nursing, Anhui Medical University, Hefei, Anhui, People’s Republic of China
- Guo-Cui WuSchool of Nursing, Anhui Medical University, 15 Feicui Road, Hefei, Anhui, 230601, People’s Republic of ChinaEmail
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Thakkar D, Piparva KG, Lakkad SG. A pilot project: 99DOTS information communication technology-based approach for tuberculosis treatment in Rajkot district. Lung India 2019; 36:108-111. [PMID: 30829243 PMCID: PMC6410600 DOI: 10.4103/lungindia.lungindia_86_18] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: 99DOTS (Directly Observed Treatment, Short course) is a low-cost, mobile phone-based technology that enables real-time remote monitoring of daily intake of treatment, first introduced by the Revised National Tuberculosis Programme under the national programme in 2015 in high-burden antiretroviral therapy (ART) centers. This project was launched for the first time in 2016 in Rajkot district, Gujarat, India, and hence this was an effort to evaluate 99DOTS. Objectives: The objective of this study was to evaluate treatment adherence rate and treatment outcome of 99DOTS-information communication technology (ICT)-based approach for tuberculosis (TB) management. Materials and Methods: Data from 99DOTS were obtained from February 2016 to September 2017 after obtaining approval from the Institutional Ethical Committee and permission from the head of the department of district TB center (DTC), Rajkot. Data were evaluated for sociodemographic pattern, adherence rate, and treatment outcome. Results: A total of total 347 registered patients, 197 (56.77%) patients diagnosed by private practitioners and 150 (43.22%) patients having HIV-TB from ART center were initiated TB treatment under 99DOTS project from nine different talukas of Rajkot district. Mean age of the registered TB patients was 36 ± 13.55 years with predominance of “new cases” (n = 275, 79.25%) and “male” gender (n = 257, 74.06%). The overall treatment adherence rate of 99DOTS was 96.03%, while adherence by “call” was 92.25% and adherence by “manual” was 32.12%. Cure rate was higher in patients with TB only (n = 113, 78.47%) as compared to patients with HIV-TB co-infection (n = 46, 67.64%). Defaulter rate (n = 19, 13.19%) was also higher in patients with TB only, while death rate (n = 14, 20.58%) was higher in patients of TB with HIV co-infection. Conclusion: 99DOTS is an effective approach for improving TB medication adherence, thereby increasing the compliance to TB treatment. It will be helpful for easy access of treatment to patients from remote areas, improve notification of patients from private practitioners, and enable differentiated care.
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Affiliation(s)
- Dharitri Thakkar
- Department of TB and Chest, P.D.U. Government Medical College, Rajkot, Gujarat, India
| | - Kiran G Piparva
- Department of Pharmacology, P.D.U. Government Medical College, Rajkot, Gujarat, India
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Viney K, Wingfield T, Kuksa L, Lönnroth K. Access and adherence to tuberculosis prevention and care for hard-to-reach groups. Tuberculosis (Edinb) 2018. [DOI: 10.1183/2312508x.10022117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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28
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A patient-level pooled analysis of treatment-shortening regimens for drug-susceptible pulmonary tuberculosis. Nat Med 2018; 24:1708-1715. [PMID: 30397355 PMCID: PMC6685538 DOI: 10.1038/s41591-018-0224-2] [Citation(s) in RCA: 188] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 09/04/2018] [Indexed: 11/08/2022]
Abstract
Tuberculosis kills more people than any other infectious disease. Three pivotal trials testing 4-month regimens failed to meet non-inferiority margins; however, approximately four-fifths of participants were cured. Through a pooled analysis of patient-level data with external validation, we identify populations eligible for 4-month treatment, define phenotypes that are hard to treat and evaluate the impact of adherence and dosing strategy on outcomes. In 3,405 participants included in analyses, baseline smear grade of 3+ relative to <2+, HIV seropositivity and adherence of ≤90% were significant risk factors for unfavorable outcome. Four-month regimens were non-inferior in participants with minimal disease defined by <2+ sputum smear grade or non-cavitary disease. A hard-to-treat phenotype, defined by high smear grades and cavitation, may require durations >6 months to cure all. Regimen duration can be selected in order to improve outcomes, providing a stratified medicine approach as an alternative to the ‘one-size-fits-all’ treatment currently used worldwide. Analysis of tuberculosis drug trials identifies features to stratify patients for longer or shorter treatment duration than the standard of care, in order to improve therapeutic outcomes.
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Subbaraman R, de Mondesert L, Musiimenta A, Pai M, Mayer KH, Thomas BE, Haberer J. Digital adherence technologies for the management of tuberculosis therapy: mapping the landscape and research priorities. BMJ Glob Health 2018; 3:e001018. [PMID: 30364330 PMCID: PMC6195152 DOI: 10.1136/bmjgh-2018-001018] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/13/2018] [Accepted: 09/14/2018] [Indexed: 11/15/2022] Open
Abstract
Poor medication adherence may increase rates of loss to follow-up, disease relapse and drug resistance for individuals with active tuberculosis (TB). While TB programmes have historically used directly observed therapy (DOT) to address adherence, concerns have been raised about the patient burden, ethical limitations, effectiveness in improving treatment outcomes and long-term feasibility of DOT for health systems. Digital adherence technologies (DATs)-which include feature phone-based and smartphone-based technologies, digital pillboxes and ingestible sensors-may facilitate more patient-centric approaches for monitoring adherence, though available data are limited. Depending on the specific technology, DATs may help to remind patients to take their medications, facilitate digital observation of pill-taking, compile dosing histories and triage patients based on their level of adherence, which can facilitate provision of individualised care by TB programmes to patients with varied levels of risk. Research is needed to understand whether DATs are acceptable to patients and healthcare providers, accurate for measuring adherence, effective in improving treatment outcomes and impactful in improving health system efficiency. In this article, we describe the landscape of DATs that are being used in research or clinical practice by TB programmes and highlight priorities for research.
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Affiliation(s)
- Ramnath Subbaraman
- Department of Public Health and Community Medicine and Tufts Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, USA
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Laura de Mondesert
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Angella Musiimenta
- Department of Information Technology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Beena E Thomas
- Department of Social and Behavioural Research, National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Jessica Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
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30
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Video Directly Observed Therapy to support adherence with treatment for tuberculosis in Vietnam: A prospective cohort study. Int J Infect Dis 2017; 65:85-89. [PMID: 29030137 DOI: 10.1016/j.ijid.2017.09.029] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 09/27/2017] [Accepted: 09/29/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Ensuring patients fully adhere to their treatment is a major challenge for TB control programmes in resource-limited settings. This study was conducted three outpatient tuberculosis clinics in Hanoi, Vietnam. We aimed to evaluate the feasibility of using asynchronous Video Directly Observed Therapy (VDOT) to support treatment adherence among patients with bacteriologically confirmed pulmonary tuberculosis. METHODS In this cohort study, consecutive adult patients with bacteriologically confirmed pulmonary TB were invited to enroll in a programme of VDOT. Patients were trained to use a smartphone to record themselves taking treatment for TB. Videos were uploaded to an online server and reviewed daily by study staff for at least two months. Adherence was evaluated based upon monthly pill count. RESULTS Between November 2016 and January 2017, 40 of 78 eligible participants (51.3%) agreed to commence VDOT. Among participating patients, 27 (71.1%) of patients took all required doses. A median of 88.4% (interquartile range 75.8%-93.7%) of doses were correctly recorded and uploaded. Participants rated the VDOT interface highly, despite facing some initial technical difficulties. CONCLUSION VDOT was feasible and resulted in high rates of treatment adherence in a resource-limited setting.
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DiStefano MJ. Wearable Biometric Technologies and Public Health. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:79-81. [PMID: 27996903 DOI: 10.1080/15265161.2016.1251643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Michael J DiStefano
- a Johns Hopkins Berman Institute of Bioethics and Bloomberg School of Public Health
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