Video directly observed therapy for supporting and monitoring adherence to tuberculosis treatment in Uganda: a pilot cohort study

Feasibility of smartphone-enabled asynchronous video directly observed therapy to improve viral suppression outcomes among HIV unsuppressed children and adolescents in Kenya

BACKGROUND

Video directly observed therapy (VDOT) has been used as an acceptable, cost-effective, client-centered intervention for tuberculosis management. VDOT targeting children (0-14 years) and adolescents (15-19 years) living with HIV (CALHIV) not achieving viral suppression (VS) [i.e., < 1000 copies/ml] was piloted in 73 facilities in Kenya. We conducted a feasibility study on the utilization and re-suppression rates of clients enrolled in VDOT.

METHODS

A review of data from 223 virally unsuppressed clients aged between 0-19 years on antiretroviral therapy (ART) who were enrolled to use the VDOT application daily for at least 12 weeks between February 2021 and October 2022 at 73 health facilities was conducted. Clients stopped using the application upon achieving VS. VS was assessed after at least 12 weeks of VDOT follow-up through self-care or healthcare worker (HCW)-led approaches. Using a multivariable Cox Proportional Hazards regression model, we assessed demographic and clinical determinants of VS presenting adjusted hazard ratios (aHR).

RESULTS

Most users, 163 (73.1%) were adolescents aged 10-19 years. Only 19 (8.5%) were on self-care VDOT. Median time on follow-up was 19 weeks, with 126 videos uploaded, and 75% VDOT adherence. Over three-fourths, 176 (78.9%) had achieved VS during follow-up. Results showed a higher likelihood of VS among children on once-daily compared to twice-daily ARV dosage, aHR = 2.51 (95% CI: 2.06 - 3.05), and those on second- or third-line regimens compared to those on first-line regimens, aHR = 3.05 (95% CI: 1.78 - 5.22). Similarly, those on a DTG-based regimen had a higher likelihood of VS compared to those on LPV/r-based, ATV/s-based, or EFV-based regimens, aHR = 1.95 (95% CI: 1.25 - 3.06). Children receiving care from guardians and siblings had a higher likelihood of VS compared to those receiving care from parent caregivers, 1.61 (95% CI: 1.27-2.03), and 2.00 (95% CI: 1.12 - 3.57), respectively.

CONCLUSION

VDOT supported the achievement of VS among unsuppressed CALHIV on antiretroviral treatment and was significantly associated with dosage frequency, antiretroviral regimen, first- or second-line therapy, antiretroviral regimen classification, and type of caregiver. Findings suggest the utility of VDOT among unsuppressed CALHIV in resource-limited settings.

Participant Adherence in Repeated-Dose Clinical Studies Using Video-Based Observation: Retrospective Data Analysis

BACKGROUND

Maintaining accurate medication records in clinical trials is essential to ensure data validity. Traditional methods such as direct observation, self-reporting, and pill counts have shown limitations that make them inaccurate or impractical. Video-based monitoring systems, available as commercial or proprietary mobile applications for smartphones and tablets, offer a promising solution to these traditional limitations. In Korea, a system applicable to the clinical trial context has been developed and used.

OBJECTIVE

This study aimed to evaluate the usefulness of an asynchronous video-based self-administration of the investigational medicinal product (SAI) monitoring system (VSMS) in ensuring accurate dosing and validating participant adherence to planned dosing times in repeated-dose clinical trials.

METHODS

A retrospective analysis was conducted using data from 17,619 SAI events in repeated-dose clinical trials using the VSMS between February 2020 and March 2023. The SAI events were classified into four categories: (1) Verified on-time dosing, (2) Verified deviated dosing, (3) Unverified dosing, and (4) Missed dosing. Analysis methods included calculating the success rate for verified SAI events and analyzing trends in difference between planned and actual dosing times (PADEV) over the dosing period and by push notification type. The mean PADEV for each subsequent dosing period was compared with the initial period using either a paired t test or a Wilcoxon signed-rank test to assess any differences.

RESULTS

A comprehensive analysis of 17,619 scheduled SAI events across 14 cohorts demonstrated a high success rate of 97% (17,151/17,619), with only 3% (468/17,619) unsuccessful due to issues like unclear video recordings or technical difficulties. Of the successful events, 99% (16,975/17,151) were verified as on-time dosing, confirming that the dosing occurred within the designated SAI time window with appropriate recorded behavior. In addition, over 90% (367/407) of participants consistently reported dosing videos on all analyzed SAI days, with most days showing over 90% objective dosing data, underscoring the system's effectiveness in supporting accurate SAI. There were cohort differences in the tendency to dose earlier or later, but no associated cohort characteristics were identified. The initial SAI behaviors were generally sustained during the whole period of participation, with only 16% (13/79) of study days showing significant shifts in actual dosing times. Earlier deviations in SAI times were observed when only dosing notifications were used, compared with using reminders together or no notifications.

CONCLUSIONS

VSMS has proven to be an effective tool for obtaining dosing information with accuracy comparable to direct observation, even in remote settings. The use of various alarm features and appropriate intervention by the investigator or observer was identified as a way to minimize adherence deterioration. It is expected that the usage and usefulness of VSMS will be continuously improved through the accumulation of experience in various medical fields.

Treatment Adherence and Outcomes in Patients with Tuberculosis Treated with Telemedicine: A Scoping Review

Patient non-adherence to drug usage is a major barrier to treating tuberculosis (TB). Telemedicine has shown promise in treatment monitoring and evaluation. This paper aims to explore scientific evidence of telemedicine application in TB treatment to promote widespread adoption in areas that are remote or have poor road networks from health facilities. Articles published from 2010 to 2023 on the adherence and outcomes in pulmonary tuberculosis with the use of telemedicine were reviewed. A scoping review of the studies was conducted by two authors independently, following the PRISMA guidelines to identify relevant articles. Telemedicine interventions have shown improvements in medication adherence, treatment completion, cure rates, and smear conversion among TB patients. The available evidence supports the beneficial effect of telemedicine in improving treatment adherence and outcomes in patients with pulmonary tuberculosis. However, the effect and outcomes varied across studies, indicating the need for further research and standardization of telemedicine interventions.

Care for adolescents with drug-susceptible pulmonary tuberculosis in Lima, Peru: a qualitative assessment

OBJECTIVE

To identify the barriers and facilitators of adolescent-friendly tuberculosis (TB) services among adolescents with drug-susceptible TB (DS-TB), as defined by the WHO's Adolescent-Friendly Services (AFS) framework, in Lima, Peru.

DESIGN

We conducted in-depth interviews using semistructured interview guides. Data were analysed using the framework method, in which themes were mapped onto four of the five dimensions of care in the WHO's AFS framework: accessibility, acceptability, appropriateness and effectiveness.

SETTING

32 public health centres operated by the Peruvian Ministry of Health in Lima from August 2018 to May 2019.

PARTICIPANTS

In-depth interviews were conducted with 34 adolescents who completed or were lost to follow-up from treatment for DS pulmonary TB disease in the preceding 12 months, their primary caregiver during treatment and 15 nurses or nurse technicians who had at least 6 months of experience supervising TB treatment.

RESULTS

We found significant barriers to adolescent-friendly TB care, including facility-based directly observed therapy, lack of functioning X-ray machines, staffing shortage of psychologists and nutritionists and inadequate educational support. However, several facilitators of adolescent-friendly care were identified: free TB care, convenient locations of health centres and strong emotional support from providers.

CONCLUSION

Improvements are needed to make TB care in Lima more accessible, acceptable, appropriate and effective for adolescents, a population with unique needs. The WHO AFS framework is a useful tool to examine the quality of TB services for adolescents.

Effectiveness and Acceptability of Video-Observed Therapy for Tuberculosis Treatment Monitoring: A Scoping Review

Background

Tuberculosis (TB) control programs confront a significant challenge in ensuring patients fully adhere to their treatment regimens. Video-observed therapy (VOT) is an alternative digital technology for monitoring tuberculosis treatment that may potentially improve adherence and clinical outcomes. However, there is limited evidence supporting the effectiveness and acceptability of VOT. This scoping review aimed to summarize the characteristics of existing evidence-based VOT for tuberculosis treatment monitoring and to describe the evidence for their effectiveness and acceptability.

Methods

This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping review protocol in Jan 2023. Three databases, namely PubMed, Web of Science, and SCOPUS, were used in this review.

Results

The search identified 170 articles, and after the identification and screening process, 22 articles were included in this review. The findings were categorized into effectiveness and acceptability.

Conclusion

There is a progressively growing body of evidence, particularly in treating and monitoring TB using VOT, which has a positive impact on improving effectiveness regarding health outcomes and is widely accepted to implement. Future studies, such as non-inferiority trials and cost-effectiveness evaluations, will help improve tuberculosis strategies and management.

A community based, bottom-up, multi-pronged, technology integrated approach to enhance tuberculosis related awareness and treatment adherence in Uganda: The ACTS model

BACKGROUND

Tuberculosis (TB) is still a major public health challenge globally and Uganda is one among the top 30 high TB burden countries. One of the key factors determining TB treatment success rates and thereby Cure Rates is the adherence to TB treatment, which is still a major challenge globally. WHO DOTS (Directly Observed Treatment Short course) strategy has several limitations and WHO End TB Strategy 2017 suggests a suite of new interventions to improve adherence.

OBJECTIVES OF THE STUDY

a. To present the development and design of ZMQ's Active Care and Treatment Strategy (ACTS) Model.b. To present the results of a pilot study done using the ACTS Model.c. To compare Treatment Adherence Rates between DOTS and Video Observed Treatment (VOT) in the four districts of Uganda.

MATERIALS AND METHODS

Includes presenting the ACTS Model, a pilot study to assess the AGB and ACF by way of a pre-post (Quasi-experimental) study (n = 1000) to assess the impact of AGB exercises, Focus Group Discussions (FGD) to get insights into factors contributing to treatment non-adherence and a comparison between VOT (n = 800) vs. DOTS for treatment adherence.

RESULTS

There was a significant improvement (p<0.01) in knowledge and awareness levels of community members post the AGB exercises which included creating awareness using digital storytelling, house visits and more. TB treatment adherence rates among TB patients using VOT was significantly better (p<0.01) than those using DOTS.

CONCLUSION

AGB and ACF play a significant role in creating more awareness amongst the community members and identifying more number of cases. It helps in better treatment seeking behaviour, improved treatment rates and treatment adherence rates and in turn better cure rates. VOT is far more superior to DOTS, as a strategy for TB treatment adherence and VOT decreases the resources required in terms of human resource, time and money and is also a more sustainable mode of treatment adherence.

Implementation outcomes of tuberculosis digital adherence technologies: a scoping review using the RE-AIM framework

INTRODUCTION

Globally, tuberculosis (TB) remains one of the leading infectious causes of death, with 1.3 million deaths. Digital adherence technologies (DATs) have the potential to provide person-centred care and improve outcomes. Using the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework, we conducted a scoping review of DAT implementations for TB treatment.

METHODS

We searched seven databases for papers published between January 2000 and April 2023, using keywords for 'tuberculosis' and 'digital adherence technology'. Articles meeting prespecified inclusion criteria and containing data on RE-AIM domains were included. We defined 'reach' as comprising cellphone ownership and engagement by people with TB (PWTB) with DATs, 'adoption' as engagement by healthcare providers with DAT programmes, 'implementation' as the fidelity of the DAT programme implemented and 'maintenance' as longer-term uptake of DATs.

RESULTS

Of 10 313 records, 102 contributed to the synthesis. DATs included short message service (SMS), phone, 99DOTS, video-supported therapy (VST) and pillboxes. For 'reach', across various settings, cellphone access varied from 50%-100% and 2%-31% of PWTB was excluded from accessing DATs due to technology challenges. 36%-100% of PWTB agreed to use a DAT. The weighted mean of DAT engagement over dose-days was 81% for SMS, 85% for phone, 61% for 99DOTS, 87% for pillbox and 82% for VST. Concerning 'implementation', the fidelity of DAT implementations was affected by technological issues such as cellphone coverage, DAT malfunction and provider-facing issues, including failure to initiate intensified patient management following low DAT engagement. Findings related to RE-AIM dimensions of 'adoption' and 'maintenance' were limited.

CONCLUSION

Our findings suggest that the 'reach' of DATs may be limited by a cascade of barriers, including limitations in cellphone accessibility and suboptimal sustained DAT engagement by PWTB. Video and pillbox DATs have higher levels of engagement. Implementation challenges included technological and provider-facing issues. Improving implementation outcomes may be important for TB DATs to achieve a broader public health impact.

PROSPERO REGISTRATION NUMBER

CRD42022326968.

Effectiveness of a Mobile Health Intervention (DOT Selfie) in Increasing Treatment Adherence Monitoring and Support for Patients With Tuberculosis in Uganda: Randomized Controlled Trial

BACKGROUND

Directly observed therapy (DOT) is the standard method for monitoring adherence to tuberculosis (TB) treatment. However, implementing DOT poses challenges for both patients and providers due to limited financial and human resources. Increasing evidence suggests that emerging digital adherence technologies, such as video directly observed therapy (VDOT), can serve as viable alternatives.

OBJECTIVE

This study aims to evaluate the effectiveness of VDOT compared with usual care directly observed therapy (UCDOT).

METHODS

Between July 2020 and October 2021, we conducted a 2-arm, parallel-group, open-label randomized trial with a 1:1 assignment to receive either the VDOT intervention (n=72) or UCDOT (n=72) for treatment adherence monitoring at public health clinics in Kampala, Uganda. Each group was further stratified to ensure equal numbers of males and females. Eligible patients were aged 18-65 years, had a confirmed diagnosis of TB, and were undergoing daily treatment. The VDOT group was provided with a smartphone equipped with an app, while the UCDOT group followed the routine monitoring practices outlined by the Uganda National TB Program. We tested the hypothesis that VDOT was more effective than UCDOT for monitoring medication adherence. The primary outcome was adherence, defined as having ≥80% of the expected doses observed during the 6-month treatment period. An intention-to-treat analysis was conducted, and multivariable logistic regression was used to estimate the effect of the intervention on adherence monitoring. Adjusted relative risk ratios and their corresponding 95% CIs are presented. Secondary outcomes included treatment completion, loss to follow-up, death, and reasons for missed videos in the intervention group.

RESULTS

The intention-to-treat analysis included 142 participants, with 2 excluded due to discontinuation of medication within the first week after enrollment. The median age of participants was 34 (IQR 26-45) years. The median fraction of expected doses observed (FEDO) was significantly higher in the VDOT group compared with the UCDOT group (100, IQR 80-100 vs 30, IQR 10-60, respectively; P<.001). When using a FEDO cutoff of ≥80% to define optimal adherence, 63 of 142 (44%) patients met the threshold, with a significant difference between the VDOT and UCDOT groups (56/71, 79% vs 7/71, 10%, P<.001). After adjusting for confounders, VDOT users were significantly more likely to achieve ≥80% of their expected doses observed compared with UCDOT users (adjusted risk ratio 8.4, 95% CI 4.16-17.0). The most common reasons for failing to submit videos of medication intake were an uncharged phone battery, forgetting to record videos during medication intake, and losing the smartphone.

CONCLUSIONS

Enhanced VDOT was more effective than UCDOT in increasing adherence monitoring among patients with TB in Uganda. This evidence highlights the potential of digital technologies to improve treatment adherence monitoring and support in high TB burden settings with limited human resources.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04134689; http://clinicaltrials.gov/ct2/show/NCT04134689.

Effectiveness of Video-Observed Therapy in Tuberculosis Management: A Systematic Review

This systematic review aimed to assess the association between video-observed therapy (VOT) and treatment adherence among TB patients and the benefits and limitations of this treatment modality. The systematic review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow guideline. Multiple databases including Cochrane, Lilacs, PubMed, Scopus, Lancet, Google Scholar, Science Direct, Directory of Open Access Journal (DOAJ), and BMC were employed to identify relevant articles published between 2012 and 2024. All data were extracted using a standardized data extraction form and both narrative and quantitative approaches were used to present the review outcomes and available evidence. Twenty-nine articles were included in the final analysis, with most using a prospective cohort (n = 10) research design. Treatment adherence rates were relatively higher in TB patients managed using VOT relative to those subjected to direct-observed therapies (DOTs). Likewise, using the VOT approach in most interventional studies lacking a control group depicted higher treatment adherence rates post-intervention. Although asynchronous VOT was used in most studies compared to the synchronous approach, the treatment adherence level was not significantly different between the two methods of VOT delivery. The predominant benefits of VOT include time-saving, cost-effectiveness, flexibility, and fewer self-reported side effects, whereas the main limitation was the privacy of patients' data and information. Video-directly observed therapy (VDOT) is a promising approach for TB treatment with the capacity to improve adherence to medication regimes and reduce the cost of treatment, stigmatization, and burden on healthcare providers.

Adherence to Short-Duration Treatment (3HP) for Latent Tuberculosis among International Migrants in Manaus, Amazonas: Evaluation of the Efficacy of Different Treatment Modalities

Migration, a multifaceted phenomenon, has a significant impact on health. Migrants perform similar movement patterns within their country of origin, in transit, and in the country of destination, thus making it difficult to monitor TB treatment throughout the journey. The objective was to compare the effectiveness of different treatment modalities in adherence to the short-term regimen for LTBI (3HP) among international migrants and refugees. This is a quasi-experimental study conducted in Manaus-AM. The study population was made up of international migrants. The certification and monitoring of medication intake employed three strategies: self-administration (SA), directly observed conventional therapy (DOT), and Video Telemonitoring System for Tuberculosis Treatment (VDOT). The VDOT group and SA group exhibited the lowest rate of treatment dropout or interruption at 16.1%, followed by the DOT group at 23.1%. The results suggest that the most effective strategy for ensuring adherence among migrants and refugees was VDOT (OR_adj 0.26; CI 0.7-0.94), suggesting that migrants may be more likely to adhere to and complete their treatment. The results show that relying on different treatment strategies, adapted to the individuals' needs and risk factors, is a viable and effective way of providing person-centered TB care.

The introduction of video-enabled directly observed therapy (video-DOT) for patients with drug-resistant TB disease in Eswatini amid the COVID-19 pandemic - a retrospective cohort study

BACKGROUND

Video-enabled directly observed therapy (video-DOT) has been proposed as an additional option for treatment provision besides in-person DOT for patients with drug-resistant TB (DRTB) disease. However, evidence and implementation experience mainly originate from well-resourced contexts. This study describes the operationalization of video-DOT in a low-resourced setting in Eswatini facing a high burden of HIV and TB amid the emergence of the COVID-19 pandemic.

METHODS

This is a retrospectively established cohort of patients receiving DRTB treatment during the implementation of video-DOT in Shiselweni from May 2020 to March 2022. We described intervention uptake (vs. in-person DOT) and assessed unfavorable DRTB treatment outcome (death, loss to care) using Kaplan-Meier statistics and multivariable Cox-regression models. Video-related statistics were described with frequencies and medians. We calculated the fraction of expected doses observed (FEDO) under video-DOT and assessed associations with missed video uploads using multivariable Poisson regression analysis.

RESULTS

Of 71 DRTB patients eligible for video-DOT, the median age was 39 (IQR 30-54) years, 31.0% (n = 22) were women, 67.1% (n = 47/70) were HIV-positive, and 42.3% (n = 30) were already receiving DRTB treatment when video-DOT became available. About half of the patients (n = 37; 52.1%) chose video-DOT, mostly during the time when COVID-19 appeared in Eswatini. Video-DOT initiations were lower in new DRTB patients (aHR 0.24, 95% CI 0.12-0.48) and those aged ≥ 60 years (aHR 0.27, 95% CI 0.08-0.89). Overall, 20,634 videos were uploaded with a median number of 553 (IQR 309-748) videos per patient and a median FEDO of 92% (IQR 84-97%). Patients aged ≥ 60 years were less likely to miss video uploads (aIRR 0.07, 95% CI 0.01-0.51). The cumulative Kaplan-Meier estimate of an unfavorable treatment outcome among all patients was 0.08 (95% CI 0.03-0.19), with no differences detected by DOT approach and other baseline factors in multivariable analysis.

CONCLUSIONS

Implementing video-DOT for monitoring of DRTB care provision amid the intersection of the HIV and COVID-19 pandemics seemed feasible. Digital health technologies provide additional options for patients to choose their preferred way to support treatment taking, thus possibly increasing patient-centered health care while sustaining favorable treatment outcomes.

Patient perceptions of video directly observed therapy for tuberculosis: a systematic review

Virtual modes of tuberculosis (TB) treatment monitoring have become increasingly relevant in the last decade with the advancements and increasing accessibility of technology. We conducted a systematic review comparing people with TB's perceptions of standard directly observed therapy (DOT) versus video directly observed therapy (vDOT). Studies were obtained from MEDLINE and EMBASE between January 1, 1974 and February 4, 2021. Of the 22 articles reviewed, a qualitative thematic analysis was performed, drawing on common themes from people with TB's perception of their care. 21 studies showed relative preference for and acceptance of vDOT over DOT. Factors that increased acceptability toward vDOT included cost and time saving, personal sense of empowerment, convenience, and privacy. Studies also showed greater adherence to treatment and subsequent improved health outcomes. vDOT has the potential to be an empowering, person-centered treatment modality for TB therapy. The role of social determinants such as place of residence, access to technology, and patient-provider communication requires further exploration.

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

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.

Low treatment success rate among previously treated persons with drug-susceptible pulmonary tuberculosis in Kampala, Uganda

Rationale

In 2017, the treatment regimen for previously treated persons with tuberculosis (TB) changed to a shorter regimen that lasts six months and consists of Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol. Few studies have examined treatment success rate (TSR) among previously treated persons with TB including the associated factors.

Objective

To determine TSR and the associated factors among previously treated persons with bacteriologically confirmed pulmonary TB on a six-month treatment regimen in Kampala, Uganda.

Methods

We retrieved data (January 2012 and December 2021) across six TB clinics in the Kampala Metropolitan area for all previously treated persons with bacteriologically confirmed pulmonary TB. TSR was defined as cure or treatment completion. Frequencies and percentages for categorical data, and the mean and standard deviation for numerical data were computed. Multivariable modified Poisson regression analysis was performed to identify factors associated with TSR, reported as adjusted risk ratio (aRR) with a 95% confidence interval (CI).

Measurements and main results

We enrolled 230 participants with a mean age of 34.8±10.6 years. TSR was 52.2% and was associated with Mycobacterium tuberculosis (MTB) sputum smear load of ≥2+ (1-10 or >10 Acid Fast Bacilli (AFB)/Field) (aRR = 0.51; 95% CI, 0.38-0.68), TB/human immunodeficiency virus (HIV) (aRR = 0.67; 95% CI, 0.51-0.88) or unknown HIV serostatus (aRR = 0.42; 95% CI, 0.26-0.68), and digital community-based directly observed therapy short-course (DOTS) (aRR = 0.42; 95% CI, 0.20-0.88).

Conclusions

The TSR among previously treated persons with bacteriologically confirmed pulmonary TB on a six-month treatment regimen is suboptimal. TSR is less likely for people with TB/HIV co-infection or unknown HIV serostatus, high MTB sputum smear load, and on digital community-based DOTs. We recommend strengthening of TB/HIV collaborative activities and people with TB with high MTB sputum smear load should receive targeted treatment support, and the contextual barriers to digital community DOTS should be addressed.

A machine learning approach to explore individual risk factors for tuberculosis treatment non-adherence in Mukono district

Despite the availability and implementation of well-known efficacious interventions for tuberculosis treatment by the Ministry of Health, Uganda (MoH), treatment non-adherence persists. Moreover, identifying a specific tuberculosis patient at risk of treatment non-adherence is still a challenge. Thus, this retrospective study, based on a record review of 838 tuberculosis patients enrolled in six health facilities, presents, and discusses a machine learning approach to explore the individual risk factors predictive of tuberculosis treatment non-adherence in the Mukono district, Uganda. Five classification machine learning algorithms, logistic regression (LR), artificial neural networks (ANN), support vector machines (SVM), random forest (RF), and AdaBoost were trained, and evaluated by computing their accuracy, F1 score, precision, recall, and the area under the receiver operating curve (AUC) through the aid of a confusion matrix. Of the five developed and evaluated algorithms, SVM (91.28%) had the highest accuracy (AdaBoost, 91.05% performed better than SVM when AUC is considered as evaluation parameter). Looking at all five evaluation parameters globally, AdaBoost is quite on par with SVM. Individual risk factors predictive of non-adherence included tuberculosis type, GeneXpert results, sub-country, antiretroviral status, contacts below 5 years, health facility ownership, sputum test results at 2 months, treatment supporter, cotrimoxazole preventive therapy (CPT) dapsone status, risk group, patient age, gender, middle and upper arm circumference, referral, positive sputum test at 5 and 6 months. Therefore, machine learning techniques, specifically classification types, can identify patient factors predictive of treatment non-adherence and accurately differentiate between adherent and non-adherent patients. Thus, tuberculosis program management should consider adopting the classification machine learning techniques evaluated in this study as a screening tool for identifying and targeting suited interventions to these patients.

Application of Artificial Intelligence to the Monitoring of Medication Adherence for Tuberculosis Treatment in Africa: Algorithm Development and Validation

Background

Artificial intelligence (AI) applications based on advanced deep learning methods in image recognition tasks can increase efficiency in the monitoring of medication adherence through automation. AI has sparsely been evaluated for the monitoring of medication adherence in clinical settings. However, AI has the potential to transform the way health care is delivered even in limited-resource settings such as Africa.

Objective

We aimed to pilot the development of a deep learning model for simple binary classification and confirmation of proper medication adherence to enhance efficiency in the use of video monitoring of patients in tuberculosis treatment.

Methods

We used a secondary data set of 861 video images of medication intake that were collected from consenting adult patients with tuberculosis in an institutional review board-approved study evaluating video-observed therapy in Uganda. The video images were processed through a series of steps to prepare them for use in a training model. First, we annotated videos using a specific protocol to eliminate those with poor quality. After the initial annotation step, 497 videos had sufficient quality for training the models. Among them, 405 were positive samples, whereas 92 were negative samples. With some preprocessing techniques, we obtained 160 frames with a size of 224 × 224 in each video. We used a deep learning framework that leveraged 4 convolutional neural networks models to extract visual features from the video frames and automatically perform binary classification of adherence or nonadherence. We evaluated the diagnostic properties of the different models using sensitivity, specificity, F1-score, and precision. The area under the curve (AUC) was used to assess the discriminative performance and the speed per video review as a metric for model efficiency. We conducted a 5-fold internal cross-validation to determine the diagnostic and discriminative performance of the models. We did not conduct external validation due to a lack of publicly available data sets with specific medication intake video frames.

Results

Diagnostic properties and discriminative performance from internal cross-validation were moderate to high in the binary classification tasks with 4 selected automated deep learning models. The sensitivity ranged from 92.8 to 95.8%, specificity from 43.5 to 55.4%, F1-score from 0.91 to 0.92, precision from 88% to 90.1%, and AUC from 0.78 to 0.85. The 3D ResNet model had the highest precision, AUC, and speed.

Conclusions

All 4 deep learning models showed comparable diagnostic properties and discriminative performance. The findings serve as a reasonable proof of concept to support the potential application of AI in the binary classification of video frames to predict medication adherence.

eHealth in TB clinical management

BACKGROUND: The constant expansion of internet and mobile technologies has created new opportunities in the field of eHealth, or the digital delivery of healthcare services. This TB meta-analysis aims to examine eHealth and its impact on TB clinical management in order to formulate recommendations for further development.METHODS: A systematic search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework in PubMed and Embase of articles published up to April 2021. Screening, extraction and quality assessment were performed by two independent researchers. Studies evaluating an internet and/or mobile-based eHealth intervention with an impact on TB clinical management were included. Outcomes were organised following the five domains described in the WHO "Recommendations on Digital Interventions for Health System Strengthening" guideline.RESULTS: Search strategy yielded 3,873 studies, and 89 full texts were finally included. eHealth tended to enhance screening, diagnosis and treatment indicators, while being cost-effective and acceptable to users. The main challenges concern hardware malfunction and software misuse.CONCLUSION: This study offers a broad overview of the innovative field of eHealth applications in TB. Different studies implementing eHealth solutions consistently reported on benefits, but also on specific challenges. eHealth is a promising field of research and could enhance clinical management of TB.

Design, development, and testing of a voice-text mobile health application to support Tuberculosis medication adherence in Uganda

Background

Tuberculosis (TB) continues to persist with a high disease burden globally. Non-adherence to treatment remains a major problem to TB control. In Uganda, one in every four TB patients does not adhere to their TB medication. The purpose of this study was to design, develop and assess implementation of a voice-text-based mobile application to support TB patients’ adherence to medication.

Methods

Design science research methodology (DSRM) was utilized to develop a voice-text-based mobile health application. Agile software methodology was used to achieve steps of DSRM that are; design and development. Focus group discussions (FGDs) and Key informant interviews (KIIs) were conducted and data analysed using thematic content analysis.

Results

During problem identification, Stigma, transport costs, being asymptomatic, drug side effects, lack of family support were identified as challenges affecting adherence. Technologies identified and used for the development of the voice-text application included; extensible mark-up language (XML) File, Apache server, Ubuntu Server, Hypertext Pre-processor, and jQuery. In the pilot study, 27 voice messages were broadcasted, 85.2% were delivered, 103 text messages were sent and 92.2% were delivered to the intended recipients.

Conclusions

Voice-text message mobile health application can be used to reach a wider patient population and it has the capability of addressing some of the challenges affecting TB medication adherence.

Digital directly observed therapy to monitor adherence to medications: a scoping review

Background: Technology-based directly observed therapy (DOT) is more cost-effective and efficient compared with in-person monitoring visits for medication adherence. While some evidence shows these technologies are feasible and acceptable, there is limited evidence collating information across medical conditions or in the context of HIV prevention, care, and treatment.Objectives: We conducted a scoping review to understand the current evidence on the acceptability, feasibility, and efficacy of digital DOT to improve medication adherence and, specifically, to determine if digital DOT had been used to improve adherence for HIV prevention, care, and treatmentMethods: We searched the electronic databases PubMed, Embase, and the Web of Science in January 2021 for any published studies with terms related to digital technologies and DOT. We included peer-reviewed studies in any population, from any country, for any outcome, and excluded conference abstracts. We included three types of digital DOT interventions: synchronous DOT, asynchronous DOT, and automated DOT. We provide an assessment of the current evidence, gaps in literature, and opportunities for intervention development regarding the use digital DOT to improve antiretroviral therapy (ART) adherence, specifically in the field of HIV.Results: We identified 28 studies that examined digital DOT. All studies found digital DOT to be acceptable and feasible. Patients using digital DOT had higher rates of treatment completion, observed doses, and adherence compared with in-person DOT, although data were limited on adherence. Only one study examined HIV prevention, and none examined ART adherence for HIV treatment.Conclusions: Digital DOT is acceptable and feasible but has not been used to remotely monitor and support ART adherence for people living with HIV.

Isoniazid adherence reduces mortality and incident tuberculosis at 96 weeks among adults initiating antiretroviral therapy with advanced HIV in multiple high burden settings

Background

People with human immunodeficiency virus (HIV) and advanced immunosuppression initiating antiretroviral therapy (ART) remain vulnerable to tuberculosis (TB) and early mortality. To improve early survival, isoniazid preventive therapy (IPT) or empiric TB treatment have been evaluated; however, their benefit on longer-term outcomes warrants investigation.

Methods

We present a 96-week preplanned secondary analysis among 850 ART-naive outpatients (≥13 years) enrolled in a multicountry, randomized trial of efavirenz-containing ART plus either 6-month IPT (n = 426) or empiric 4-drug TB treatment (n = 424). Inclusion criteria were CD4 count <50 cells/mm³ and no confirmed or probable TB. Death and incident TB were compared by strategy arm using the Kaplan-Meier method. The impact of self-reported adherence (calculated as the proportion of 100% adherence) was assessed using Cox-proportional hazards models.

Results

By 96 weeks, 85 deaths and 63 TB events occurred. Kaplan-Meier estimated mortality (10.1% vs 10.5%; P = .86) and time-to-death (P = .77) did not differ by arm. Empiric had higher TB risk (6.1% vs 2.7%; risk difference, −3.4% [95% confidence interval, −6.2% to −0.6%]; P = .02) and shorter time to TB (P = .02) than IPT. Tuberculosis medication adherence lowered the hazards of death by ≥23% (P < .0001) in empiric and ≥20% (P < .035) in IPT and incident TB by ≥17% (P ≤ .0324) only in IPT.

Conclusions

Empiric TB treatment offered no longer-term advantage over IPT in our population with advanced immunosuppression initiating ART. High IPT adherence significantly lowered death and TB incidence through 96 weeks, emphasizing the benefit of ART plus IPT initiation and completion, in persons with advanced HIV living in high TB-burden, resource-limited settings.

Ethical, Legal, and Sociocultural Issues in the Use of Mobile Technologies and Call Detail Records Data for Public Health in the East African Region: Scoping Review

BACKGROUND

The exponential scale and pace of real-time data generated from mobile phones present opportunities for new insights and challenges across multiple sectors, including health care delivery and public health research. However, little attention has been given to the new ethical, social, and legal concerns related to using these mobile technologies and the data they generate in Africa.

OBJECTIVE

The objective of this scoping review was to explore the ethical and related concerns that arise from the use of data from call detail records and mobile technology interventions for public health in the context of East Africa.

METHODS

We searched the PubMed database for published studies describing ethical challenges while using mobile technologies and related data in public health research between 2000 and 2020. A predefined search strategy was used as inclusion criteria with search terms such as "East Africa," "mHealth," "mobile phone data," "public health," "ethics," or "privacy." We screened studies using prespecified eligibility criteria through a two-stage process by two independent reviewers. Studies were included if they were (1) related to mobile technology use and health, (2) published in English from 2000 to 2020, (3) available in full text, and (4) conducted in the East African region. We excluded articles that (1) were conference proceedings, (2) studies presenting an abstract only, (3) systematic and literature reviews, (4) research protocols, and (5) reports of mobile technology in animal subjects. We followed the five stages of a published framework for scoping reviews recommended by Arksey and O'Malley. Data extracted included title, publication year, target population, geographic region, setting, and relevance to mobile health (mHealth) and ethics. Additionally, we used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Extension for Scoping Reviews checklist to guide the presentation of this scoping review. The rationale for focusing on the five countries in East Africa was their geographic proximity, which lends itself to similarities in technology infrastructure development.

RESULTS

Of the 94 studies identified from PubMed, 33 met the review inclusion criteria for the final scoping review. The 33 articles retained in the final scoping review represent studies conducted in three out of five East African countries: 14 (42%) from Uganda, 13 (39%) from Kenya, and 5 (16%) from Tanzania. Three main categories of concerns related to the use of mHealth technologies and mobile phone data can be conceptualized as (1) ethical issues (adequate informed consent, privacy and confidentiality, data security and protection), (2) sociocultural issues, and (3) regulatory/legal issues.

CONCLUSIONS

This scoping review identified major cross-cutting ethical, regulatory, and sociocultural concerns related to using data from mobile technologies in the East African region. A comprehensive framework that accounts for the critical concerns raised would be valuable for guiding the safe use of mobile technology data for public health research purposes.

Technologies for Medication Adherence Monitoring and Technology Assessment Criteria: Narrative Review

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.

Tuberculosis treatment within differentiated service delivery models in global HIV/TB programming

Introduction

Providing more convenient and patient‐centred options for service delivery is a priority within global HIV programmes. These efforts improve patient satisfaction and retention and free up time for providers to focus on new HIV diagnoses or severe illness. Recently, the coronavirus disease 2019 (COVID‐19) pandemic precipitated expanded eligibility criteria for these differentiated service delivery (DSD) models to decongest clinics and protect patients and healthcare workers. This has resulted in dramatic scale‐up of DSD for antiretroviral therapy, cotrimoxazole and tuberculosis (TB) preventive treatment. While TB treatment among people living with HIV (PLHIV) has traditionally involved frequent, facility‐based management, TB treatment can also be adapted within DSD models. Such adaptations could include electronic tools to ensure appropriate clinical management, treatment support, adherence counselling and adverse event (AE) monitoring. In this commentary, we outline considerations for DSD of TB treatment among PLHIV, building on best practices from global DSD model implementation for HIV service delivery.

Discussion

In operationalizing TB treatment in DSD models, we consider the following: what activity is being done, when or how often it takes place, where it takes place, by whom and for whom. We discuss considerations for various programme elements including TB screening and diagnosis; medication dispensing; patient education, counselling and support; clinical management and monitoring; and reporting and recording. General approaches include multi‐month dispensing for TB medications during intensive and continuation phases of treatment and standardized virtual adherence and AE monitoring. Lastly, we provide operational examples of TB treatment delivery through DSD models, including a conceptual model and an early implementation experience from Zambia.

Conclusions

COVID‐19 has catalysed the rapid expansion of differentiated patient‐centred service delivery for PLHIV. Expanding DSD models to include TB treatment can capitalize on existing platforms, while providing high‐quality, routine treatment, follow‐up and patient education and empowerment.

Stakeholders' Perceptions of Benefits of and Barriers to Using Video-Observed Treatment for Monitoring Patients With Tuberculosis in Uganda: Exploratory Qualitative Study

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.

Assessing private provider perceptions and the acceptability of video observed treatment technology for tuberculosis treatment adherence in three cities across Viet Nam

BACKGROUND

The World Health Organization recently recommended Video Observed Therapy (VOT) as one option for monitoring tuberculosis (TB) treatment adherence. There is evidence that private sector TB treatment has substandard treatment follow-up, which could be improved using VOT. However, acceptability of VOT in the private sector has not yet been evaluated.

METHODS

We conducted a cross-sectional survey employing a theoretical framework for healthcare intervention acceptability to measure private provider perceptions of VOT across seven constructs in three cities of Viet Nam: Ha Noi, Ho Chi Minh City, and Hai Phong. We investigated the differences in private providers' attitudes and perceptions of VOT using mixed ordinal models to test for significant differences in responses between groups of providers stratified by their willingness to use VOT.

RESULTS

A total of 79 private providers completed the survey. Sixty-two providers (75%) indicated they would use VOT if given the opportunity. Between private providers who would and would not use VOT, there were statistically significant differences (p≤0.001) in the providers' beliefs that VOT would help identify side effects faster and in their confidence to monitor treatment and provide differentiated care with VOT. There were also significant differences in providers' beliefs that VOT would save them time and money, address problems faced by their patients, benefit their practice and patients, and be relevant for all their patients.

CONCLUSION

Private providers who completed the survey have positive views towards using VOT and specific subpopulations acknowledge the value of integrating VOT into their practice. Future VOT implementation in the private sector should focus on emphasizing the benefits and relevance of VOT during recruitment and provide programmatic support for implementing differentiated care with the technology.

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

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

Perceptions and Acceptability of Digital Interventions Among Tuberculosis Patients in Cambodia: Qualitative Study of Video-Based Directly Observed Therapy

Background

Despite the development of effective drugs for treatment, tuberculosis remains one of the leading causes of death from an infectious disease worldwide. One of the greatest challenges to tuberculosis control is patient adherence to treatment. Recent research has shown that video-based directly observed therapy is a feasible and effective approach to supporting treatment adherence in high-income settings. However, few studies have explored the potential for such a solution in a low- or middle-income country setting. Globally, these countries’ rapidly rising rate of mobile penetration suggests that the potential for translation of these results may be high.

Objective

We sought to examine patient perceptions related to the use of mobile health, and specifically video-based directly observed therapy, in a previously unstudied patient demographic: patients with tuberculosis in a low-income country setting (Cambodia).

Methods

We conducted a cross-sectional qualitative study in urban and periurban areas in Cambodia, consisting of 6 focus groups with tuberculosis patients who were receiving treatment (standard directly observed therapy) through a nongovernmental organization.

Results

Familiarity with mobile technology and apps was widespread in this population, and overall willingness to consider a mobile app for video-based directly observed therapy was high. However, we identified potential challenges. First, patients very much valued their frequent in-person interactions with their health care provider, which may be reduced with the video-based directly observed therapy intervention. Second, there may be technical issues to address, including how to make the app suitable for illiterate participants.

Conclusions

While video-based directly observed therapy is a promising technology, even in country settings where mobile penetration is reportedly almost universal, it should be introduced with caution. However, the results were generally promising and yielded important insights that not only will be translated into the further adaptation of key features of video-based directly observed therapy for tuberculosis patients in Cambodia, but also can inform the future design and successful implementation of video-based directly observed therapy interventions in low- and middle-income settings more generally.