Increasing Latino adolescents' adherence to treatment for latent tuberculosis infection: a controlled trial

Testing and Scaling Interventions to Improve the Tuberculosis Infection Care Cascade

Tuberculosis (TB) preventive therapy (TPT) is increasingly recognized as the key to eliminating tuberculosis globally and is particularly critical for children with TB infection or who are in close contact with individuals with infectious TB. But many barriers currently impede successful scale-up to provide TPT to those at high risk of TB disease. The cascade of care in TB infection (and the related contact management cascade) is a conceptual framework to evaluate and improve the care of persons who are potential candidates for TPT. This review summarizes recent literature on barriers and solutions in the TB infection care cascade, focusing on children in both high- and low-burden settings, and drawing from studies on children and adults. Identifying and closing gaps in the care cascade will require the implementation of tools that are new (e.g. computer-assisted radiography) and old (e.g. efficient contact tracing), and will be aided by innovative implementation study designs, quality improvement methods, and shared clinical practice with primary care providers.

Patient contracts for chronic medical conditions: Scoping review

OBJECTIVE

To describe how and why patient contracts are used for the management of chronic medical conditions.

DATA SOURCES

A scoping review was conducted in the following databases: MEDLINE, Embase, AMED, PsycInfo, Cochrane Library, CINAHL, and Nursing & Allied Health. Literature from 1997 to 2017 was included.

STUDY SELECTION

Articles were included if they were written in English and described the implementation of a patient contract by a health care provider for the management of a chronic condition. Articles had to present an outcome as a result of using the contract or an intervention that included the contract.

SYNTHESIS

Of the 7528 articles found in the original search, 76 met the inclusion criteria for the final review. Multiple study types were included. Extensive variety in contract elements, target populations, clinical settings, and cointerventions was found. Purposes for initiating contracts included behaviour change and skill development, including goal development and problem solving; altering beliefs and knowledge, including motivation and perceived self-efficacy; improving interpersonal relationships and role clarification; improving quality and process of chronic care; and altering objective and subjective health indices. How contracts were developed, implemented, and assessed was inconsistently described.

CONCLUSION

More research is required to determine whether the use of contracts is accomplishing their intended purposes. Questions remain regarding their rationale, development, and implementation.

Digital health use in latent tuberculosis infection care: A systematic review

PURPOSE

With one-quarter of the world's population estimated to have latent tuberculosis infection (LTBI), it is important that the drop-outs from the LTBI cascade of care are minimized. Digital health technology could play an important role in case detection and treatment adherence. This study aims to evaluate the use and impact of digital health technology in LTBI care.

METHODS

A systematic literature search was conducted on six electronic databases from database inception until May 31st 2021. Studies that reported on the clinical use or economic analysis of digital health technology for LTBI care were included. Two investigators independently evaluated, extracted relevant studies, and assessed the risk of bias of using the Cochrane tools. The studies were synthesized qualitatively.

RESULTS

Fifteen articles describing 14 studies were included. Voice and/or textual reminders and synchronous video call to improve LTBI treatment adherence were the most commonly examined digital health interventions. Other interventions examined the use of mobile phones to improve the number of patients who returned for tuberculin skin test follow-up measurement (screening retention) and eLearning videos to enhance health literacy in LTBI care. The economic analysis supported the use of textual reminders in LTBI treatment as a cost-effective option for widescale implantation.

CONCLUSIONS

Despite limited evidence on the effects of digital health technologies in LTBI, available studies suggest they are at least equivalent to current practice. This means digital health can potentially supplement current practice, to constantly monitor and engage with people undergoing LTBI screening or treatment, as an initiative to ensure the provision of continuous and optimal care to all LTBI-affected individuals.

Biculturalism and adjustment among U.S. Latinos: A review of four decades of empirical findings

Incorporating both heritage (e.g., Latino) and national (e.g., American) cultural systems into our sense of self (i.e., bicultural identity) and developing the ability to successfully respond to demands associated with each of these systems (i.e., bicultural competence) have been theorized to be central to the development and positive adjustment of U.S. Latinos, a group that represents a large segment of the country's population. In this comprehensive review, we examined empirical research on biculturalism among U.S. Latinos spanning four decades (1980-2020), with a focus on synthesizing the field's understanding of antecedents and consequents associated with biculturalism and identifying directions for future research. Our review of 152 empirical articles revealed that this literature was characterized by multiple approaches to the conceptualization (i.e., dual-cultural adaptation, dual-cultural identity, bicultural identity integration, and bicultural competence) and subsequent operationalization of biculturalism. Although each conceptualization has different implications for the conclusions that can be drawn regarding an aspect or facet of biculturalism and potential influence on adjustment, a significant majority (78%) of studies, across conceptualizations, provided evidence supporting a positive association between biculturalism and Latinos' adjustment. In addition, a relatively small body of qualitative work was identified, and findings largely informed potential antecedents of biculturalism. We review this literature with attention to: the aspects of biculturalism that are associated with Latinos' adjustment (i.e., psychosocial and physical health), how sample characteristics may limit the generalizability of this work, and important directions for future research both in terms of conceptualization and study design.

Development of integrated model of communication for implementing media strategy to prevent hypertension in a northern state of India

OBJECTIVE

Media plays a major role in inculcating positive changes or averting negative changes in health-related behaviors across populations. Although various mass media interventions have proven their effectiveness in changing individuals' behavior for various diseases and risk factors, current literature is limited regarding a conceptual framework/model for the prevention of hypertension and cardiovascular diseases. The present study describes the process of development and implementation of a comprehensive and need-based media strategy with an aim to generate politico-administrative support for strengthening hypertension services in the state of Punjab, India.

METHODS

The preparation of theoretical framework underwent two stages, that is, item generation and item reduction. The item generation involved extensive literature search, development of consensus among experts using Delphi technique and its validation. The item reduction involved the selection of models among existing communication and health promotion models, placement of items in the selected models and development of final conceptual framework model.

RESULTS

Based upon the review and expert's consensus, we zeroed in on three models of communication - communication campaign model, paid earned social owned model, and staircase model - in order to come up with the framework requisite for a systematic media strategy. The model focused upon context-specific messages involving both traditional and modern means and tools of communication. This model (conceptual framework) was the product of intense literature review followed by opinion of the experts from various disciplines such as medical professionals, public health specialists, communication experts, social scientists, politicians, bureaucrats, state-level representatives, media journalists and hypertensive patients.

CONCLUSION

The present model can effectively be used by the program implementers, educators and policy makers in similar settings.

A scoping review of paediatric latent tuberculosis infection care cascades: initial steps are lacking

BACKGROUND AND OBJECTIVES

Identifying and treating children with latent tuberculosis infection (TB infection) is critical to prevent progression to TB disease and to eliminate TB globally. Diagnosis and treatment of TB infection requires completion of a sequence of steps, collectively termed the TB infection care cascade. There has been no systematic attempt to comprehensively summarise literature on the paediatric TB infection care cascade.

METHODS

We performed a scoping review of the paediatric TB infection care cascade. We systematically searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Cochrane and Embase databases. We reviewed articles and meeting abstracts that included children and adolescents ≤21 years old who were screened for or diagnosed with TB infection, and which described completion of at least one step of the cascade. We synthesised studies to identify facilitators and barriers to retention, interventions to mitigate attrition and knowledge gaps.

RESULTS

We identified 146 studies examining steps in the paediatric TB infection care cascade; 31 included children living in low-income and middle-income countries. Most literature described the final cascade step (treatment initiation to completion). Studies identified an array of patient and caregiver-related factors associated with completion of cascade steps. Few health systems factors were evaluated as potential predictors of completion, and few interventions to improve retention were specifically tested.

CONCLUSIONS

We identified strengths and gaps in the literature describing the paediatric TB infection care cascade. Future research should examine cascade steps upstream of treatment initiation and focus on identification and testing of at-risk paediatric patients. Additionally, future studies should focus on modifiable health systems factors associated with attrition and may benefit from use of behavioural theory and implementation science methods to improve retention.

Effects of programmatic interventions to improve the management of latent tuberculosis: a follow up study up to five months after implementation

Background

Less than 19% of those needing tuberculosis (TB) preventive treatment complete it, due to losses in several steps of the cascade of care for latent TB infection. A cluster randomized trial of a programmatic public health intervention to improve management of latent TB infection in household contacts was conducted in Rio de Janeiro. Interventions included contact registry, initial and in-service training, and a TB booklet. We conducted a follow-up study starting one month after the conclusion of this trial, to measure the effect of interventions implemented, and to identify remaining barriers and facilitators to latent TB infection treatment, from different perspectives.

Methods

In two health clinics in Rio de Janeiro that received the interventions in the trial, data for the latent TB infection cascade of care for household contacts was collected over a five-month period. The number of household contacts initiating treatment per 100 index-TB patients was compared with the cascade of care data obtained before and during the intervention trial. Semi-structured open-ended questionnaires were administered to healthcare workers, household contacts and index-TB patients regarding knowledge and perceptions about TB and study interventions.

Results

In this follow-up study, 184 household contacts per 100 index-TB patients were identified. When compared to the intervention period, there were 65 fewer household contacts per 100 index-TB patients, (95% CI -115, − 15) but the number starting latent TB infection treatment was sustained (difference -2, 95% CI -8,5). A total of 31 index-TB patients, 22 household contacts and 19 health care workers were interviewed. Among index-TB patients, 61% said all their household contacts had been tested for latent TB infection. All health care workers said it was very important to test household contacts, and 95% mentioned that possessing correct knowledge on the benefits of latent TB infection treatment was the main facilitator to enable them to recommend this treatment.

Conclusion

In this follow-up study, we observed a sustained effect of interventions to strengthen the latent TB infection cascade of care on increasing the number of household contacts starting latent TB infection treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10195-z.

Interventions to improve medication adherence in tuberculosis patients: a systematic review of randomized controlled studies

Non-adherence to anti-tuberculosis (anti-TB) medication is a major risk factor for poor treatment outcomes. We therefore assessed the effectiveness of medication adherence enhancing interventions in TB patients. We report a systematic review of randomized controlled trials that included either latent tuberculosis infection (LTBI) or active TB patients. Outcomes of interest included adherence rate, completed treatment, defaulted treatment and treatment outcomes. We identified four LTBI and ten active TB studies. In active TB patients, directly observed treatment (DOT) by trained community workers, short messaging service combined with education, counselling, monthly TB vouchers, drug box reminders and combinations of those were found effective. In LTBI patients, shorter regimens and DOT effectively improved treatment completion. Interestingly, DOT showed variable effectiveness, highlighting that implementation, population and setting may play important roles. Since non-adherence factors are patient-specific, personalized interventions are required to enhance the impact of a programme to improve medication adherence in TB patients.

Leukocyte telomere length as a diagnostic biomarker for anti-tuberculosis drug-induced liver injury

Despite being relatively rare, anti-tuberculosis drug-induced liver injury (ATDILI) is a leading cause of acute liver failure and a major reason for treatment discontinuation, because of no specific and selective markers for ATDILI. Herein, this study aimed to investigate whether telomere length, a biological indicator of age-related diseases, is associated with ATDILI outcomes and could serve as an early ATDILI biomarker. Relative telomere length (RTL) in blood leukocyte of 100 age- and gender-matched healthy controls, 49 tuberculosis patients with ATDILI, and 53 tuberculosis patients with non-ATDILI was quantified using real-time polymerase chain reaction. Both tuberculosis patients with and without ATDILI had significantly shorter RTL than healthy controls. Compared with tuberculosis patients with non-ATDILI, RTL in those with ATDILI was significantly increased. Longer RTL was found to be significantly associated with increased susceptibility to ATDILI. Multivariate linear regression analysis showed that an increment in RTL was independently correlated with elevated values of aspartate aminotransferase and alanine aminotransferase assessed within 60 days after anti-tuberculosis treatment. Kaplan-Meier curve analysis demonstrated that longer RTL was associated with elevated rates of hepatotoxicity in tuberculosis patients. Receiver-operating characteristic curve analysis unveiled a diagnostic accuracy of RTL as a novel indicator for ATDILI progression (AUC = 0.73), which yielded more sensitive and specific values than traditional liver biomarkers including serum enzyme activities of aminotransferases measured within 7 days after treatment with anti-tuberculosis regimens. Collectively, aberrant RTL in blood leukocyte would reflect hepatotoxicity induced by anti-tuberculosis agents and might have a potential biomarker for early ATDILI progression.

A systematic review of non-pharmacological interventions to improve therapeutic adherence in tuberculosis

BACKGROUND

Reviews examining non-pharmacological interventions to improve therapeutic adherence in tuberculosis have several limitations (design, quality assessment…). Consequently, for clinical practice, it is important to generate a review containing all the information to improve patient adherence, solving the previous issues.

OBJECTIVES

To examine non-pharmacological interventions to improve therapeutic adherence in tuberculosis through clinical trials.

METHODS

A systematic review in MEDLINE/EMBASE was performed.

RESULTS

Thirty seven papers were analysed. The disease treatment interventions were disparate, grouped into: education, psychological interventions, new technologies, directly observed treatment, incentives and improved access to health services. In the treatment of latent infection, the majority of studies were conducted in the marginal population (drug addicts, homeless individuals and prisoners) and were based mainly on the provision of incentives. Study quality was generally low.

CONCLUSIONS

Great variability exists in the studies comparing strategies for identifying interventions, objectives and effects. The designs carried out generally have methodological deficits.

Interventions to Promote Oral Medication Adherence in the Pediatric Chronic Illness Population: A Systematic Review From the Children's Oncology Group

Pediatric oncology protocols frequently include multiple oral medications administered at varied dosing schedules, often for prolonged periods of time. Nonadherence to protocol-directed oral medications may place patients at increased risk for morbidity and mortality. The purpose of this systematic review was to evaluate the existing body of evidence to determine best-practice recommendations regarding interventions for oral medication adherence in children and adolescents with cancer. Twenty-four articles were systematically reviewed and evaluated according to the Grading of Recommendations, Assessment, Development, and Evaluation criteria; 2 studies focused on the pediatric oncology population, and the remaining 22 studies focused on other chronic illnesses of childhood. A variety of interventions to increase oral medication adherence in children were identified, including pill swallowing, technology, incentivization, education-based intervention, psychosocial support-based intervention, and combination intervention. Most interventions were shown to have some benefit in pediatrics, most in the non-oncology setting. The overall synthesis of the literature indicates that nonadherence to oral medications is a prevalent problem in pediatrics, and much work is needed to address this problem, particularly in pediatric oncology.

Lessons learned from two interventions designed to increase adherence to LTBI treatment in Latino youth

Effort is required to meet the Healthy People 2020 goal of tuberculosis (TB) disease reduction to 1 new case per 100,000 in the United States (US) and reduce burden among those disparately affected. Preventing new cases by reducing conversion from latent TB infection (LTBI) to infectious disease is one approach to reducing disease burden. This paper describes the outcome of a trial designed to determine if LTBI-positive youth prescribed daily Isoniazid with peer counseling would achieve higher adherence than attention control participants. The paper also compares adherence to a previous trial. 263 students age 15.9 years (SD = 1.2), 51.7% female, 96.2% Latino, 43.7% foreign-born were randomly assigned to condition. Adherence was measured by self-report validated by metabolite analysis. Outcome analyses used number of pills taken and proportion of youth consuming 80% of medication. There was no significant difference by condition for either analysis. Thirty-seven percent of adherence participants completed treatment versus 40% of controls. Without a usual-care control group we were unable to determine whether conditions were equally effective or ineffective. The study's inability to pay for treatment resulted in the intervention being tested in the context of compromised access to care. Still to be determined is whether same-age peers can influence adherence among Latino adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT00233168.

Burden of non-adherence to latent tuberculosis infection drug therapy and the potential cost-effectiveness of adherence interventions in Canada: a simulation study

OBJECTIVE

Pharmaceutical treatment of latent tuberculosis infection (LTBI) reduces the risk of progression to active tuberculosis (TB); however, poor adherence tempers the protective effect. We aimed to estimate the health burden of non-adherence, the maximum allowable cost of hypothetical new adherence interventions to be cost-effective and the potential value of existing adherence interventions for patients with low-risk LTBI in Canada.

DESIGN

A microsimulation model of LTBI progression over 25 years.

SETTING

General practice in Canada.

PARTICIPANTS

Individuals with LTBI who are initiating drug therapy.

INTERVENTIONS

A hypothetical intervention with a range of effectiveness was evaluated. Existing drug adherence interventions including peer support, two-way text messaging support, enhanced adherence counselling and adherence incentives were also evaluated.

PRIMARY AND SECONDARY OUTCOME MEASURES

Simulation outcomes included healthcare costs, TB incidence, TB deaths and quality-adjusted life years (QALYs). Base case results were interpreted against a willingness-to-pay threshold of $C50 000/QALY.

RESULTS

Compared with current adherence levels, full adherence to LTBI drug therapy could reduce new TB cases from 90.3 cases per 100 000 person-years to 35.9 cases per 100 000 person-years and reduce TB-related deaths from 7.9 deaths per 100 000 person-years to 3.1 deaths per 100 000 person-years. An intervention that increases relative adherence by 40% would bring the population near full adherence to drug therapy and could have a maximum allowable annual cost of approximately $C450 per person to be cost-effective. Based on estimates of effect sizes and costs of existing adherence interventions, we found that they yielded between 900 and 2400 additional QALYs per million people, reduced TB deaths by 5%-25% and were likely to be cost-effective over 25 years.

CONCLUSION

Full adherence could reduce the number of future TB cases by nearly 60%, offsetting TB-related costs and health burden. Several existing interventions are could be cost-effective to help achieve this goal.

Beyond pills and tests: addressing the social determinants of tuberculosis

Poverty drives tuberculosis (TB) rates but the approach to TB control has been disproportionately biomedical. In 2015, the World Health Organization's End TB Strategy explicitly identified the need to address the social determinants of TB through socio-economic interventions. However, evidence concerning poverty reduction and cost mitigation strategies is limited. The research described in this article, based on the 2016 Royal College of Physicians Linacre Lecture, aimed to address this knowledge gap. The research was divided into two phases: the first phase was an analysis of a cohort study identifying TB-related costs of TB-affected households and creating a clinically relevant threshold above which those costs became catastrophic; the second was the design, implementation and evaluation of a household randomised controlled evaluation of socio-economic support to improve access to preventive therapy, increase TB cure, and mitigate the effects of catastrophic costs. The first phase showed TB remains a disease of people living in poverty - 'free' TB care was unaffordable for impoverished TB-affected households and incurring catastrophic costs was associated with as many adverse TB treatment outcomes (including death, failure of treatment, lost to follow-up and TB recurrence) as multidrug resistant (MDR) TB. The second phase showed that, in TB-affected households receiving socio-economic support, household contacts were more likely to start and adhere to TB preventive therapy, TB patients were more likely to be cured and households were less likely to incur catastrophic costs. In impoverished Peruvian shantytowns, poverty remains inextricably linked with TB and incurring catastrophic costs predicted adverse TB treatment outcome. A novel socio-economic support intervention increased TB preventive therapy uptake, improved TB treatment success and reduced catastrophic costs. The impact of the intervention on TB control is currently being evaluated by the Community Randomized Evaluation of a Socio-economic Intervention to Prevent TB (CRESIPT) study.

Beyond pills and tests: addressing the social determinants of tuberculosis

Poverty drives tuberculosis (TB) rates but the approach to TB control has been disproportionately biomedical. In 2015, the World Health Organization's End TB Strategy explicitly identified the need to address the social determinants of TB through socio-economic interventions. However, evidence concerning poverty reduction and cost mitigation strategies is limited. The research described in this article, based on the 2016 Royal College of Physicians Linacre Lecture, aimed to address this knowledge gap. The research was divided into two phases: the first phase was an analysis of a cohort study identifying TB-related costs of TB-affected households and creating a clinically relevant threshold above which those costs became catastrophic; the second was the design, implementation and evaluation of a household randomised controlled evaluation of socio-economic support to improve access to preventive therapy, increase TB cure, and mitigate the effects of catastrophic costs. The first phase showed TB remains a disease of people living in poverty - 'free' TB care was unaffordable for impoverished TB-affected households and incurring catastrophic costs was associated with as many adverse TB treatment outcomes (including death, failure of treatment, lost to follow-up and TB recurrence) as multidrug resistant (MDR) TB. The second phase showed that, in TB-affected households receiving socio-economic support, household contacts were more likely to start and adhere to TB preventive therapy, TB patients were more likely to be cured and households were less likely to incur catastrophic costs. In impoverished Peruvian shantytowns, poverty remains inextricably linked with TB and incurring catastrophic costs predicted adverse TB treatment outcome. A novel socio-economic support intervention increased TB preventive therapy uptake, improved TB treatment success and reduced catastrophic costs. The impact of the intervention on TB control is currently being evaluated by the Community Randomized Evaluation of a Socio-economic Intervention to Prevent TB (CRESIPT) study.

Latent Tuberculosis Infection Among Immigrant and Refugee Children Arriving in the United States: 2010

Immigrants and refugees age 2-14 years entering the United States from countries with estimated tuberculosis (TB) incidence rate ≥20 per 100,000 population are screened for TB. Children with TB disease are treated before US arrival. Children with positive tuberculin skin tests (TST), but negative TB evaluation during their pre-immigration examination, are classified with latent TB infection (LTBI) and are recommended for re-evaluation post-arrival. We examined post-immigration TB evaluation and therapy for children arriving with LTBI. We reviewed medical exam data from immigrant children with medical conditions and all refugee children arriving during 2010. Medical examination data were available for 67,334 children. Of these, 8231 (12 %) had LTBI pre-immigration; 5749 (70 %) were re-evaluated for TB post-immigration, and 64 % were retested by TST or IGRA. The pre-immigration LTBI diagnosis was changed for 38 % when retested by TST and for 71 % retested by IGRA. Estimated LTBI therapy initiation and completion rates were 68 and 12 %. In this population, testing with IGRA may limit the number of children targeted for therapy. Increased pre-immigration TB screening with post-immigration follow-up evaluation leading to completion of LTBI therapy should be encouraged to prevent TB reactivation.

Interventions for improving adherence to treatment for latent tuberculosis infection: a systematic review

BACKGROUND

Latent tuberculosis infection (LTBI) control relies on high initiation and completion rates of preventive treatment to preclude progression to tuberculosis disease. Specific interventions may improve initiation and completion rates. The objective was to systematically review data on determinants of initiation, adherence and completion of LTBI treatment, and on interventions to improve initiation and completion.

METHODS

A systematic review of the literature (PubMed, Embase) published up to February 2014 was performed. Relevant prospective intervention studies were assessed using GRADE.

RESULTS

Sixty-two articles reporting on determinants of treatment initiation and completion were included and 23 articles on interventions. Determinants of LTBI treatment completion include shorter treatment regimen and directly observed treatment (DOT, positive association), adverse events and alcohol use (negative association), and specific populations with LTBI (both positive and negative associations). A positive effect on completion was noted in intervention studies that used short regimens and social interventions; mixed results were found for intervention studies that used DOT or incentives.

CONCLUSION

LTBI treatment completion can be improved by using shorter regimens and social interventions. Specific needs of the different populations with LTBI should be addressed taking into consideration the setting and condition in which the LTBI treatment programme is implemented.

Early monitoring for detection of antituberculous drug-induced hepatotoxicity

BACKGROUND/AIMS

We investigated the time of onset of antituberculous drug-induced hepatotoxicity (ADIH) and related characteristics.

METHODS

Adult patients (n = 1,031) treated with first-line antituberculous drugs between February 2009 and January 2013 were enrolled.

RESULTS

Of the 1,031 patients, 108 patients (10.5%) developed ADIH a mean of 39.6 ± 43.7 days after treatment initiation. Twenty-eight patients (25.9%) developed ADIH within 7 days, 73 (67.6%) within 30 days, and the rest after 30 days. The ≤ 30-day group was characterized by higher peak alanine aminotransferase (ALT) level and a high proportion of patients with maintenance of first-line antituberculous drugs compared to the > 30-day group. In subgroup analysis, the ≤ 7-day group was characterized by higher baseline aspartate aminotransferase and ALT, high proportion of patients with maintenance of first-line antituberculous drugs, and high proportion of patients with extrapulmonary tuberculosis compared to patients with ADIH that developed beyond 7 days. In multivariate analysis, serum ALT > 40 IU/L (odds ratio [OR], 2.995; 95% confidence interval [CI], 1.580 to 5.680; p = 0.001) and presence of anti-hepatitis C virus (OR, 4.204; 95% CI, 1.822 to 9.700, p = 0.001) were independent risk factors for development of ADIH.

CONCLUSIONS

Approximately 70% of the cases of ADIH occurred in the first month of antituberculous treatment, and were associated with continuation of the first-line drug regimen.

Management of latent Mycobacterium tuberculosis infection: WHO guidelines for low tuberculosis burden countries

Latent tuberculosis infection (LTBI) is characterised by the presence of immune responses to previously acquired Mycobacterium tuberculosis infection without clinical evidence of active tuberculosis (TB). Here we report evidence-based guidelines from the World Health Organization for a public health approach to the management of LTBI in high risk individuals in countries with high or middle upper income and TB incidence of <100 per 100 000 per year. The guidelines strongly recommend systematic testing and treatment of LTBI in people living with HIV, adult and child contacts of pulmonary TB cases, patients initiating anti-tumour necrosis factor treatment, patients receiving dialysis, patients preparing for organ or haematological transplantation, and patients with silicosis. In prisoners, healthcare workers, immigrants from high TB burden countries, homeless persons and illicit drug users, systematic testing and treatment of LTBI is conditionally recommended, according to TB epidemiology and resource availability. Either commercial interferon-gamma release assays or Mantoux tuberculin skin testing could be used to test for LTBI. Chest radiography should be performed before LTBI treatment to rule out active TB disease. Recommended treatment regimens for LTBI include: 6 or 9 month isoniazid; 12 week rifapentine plus isoniazid; 3-4 month isoniazid plus rifampicin; or 3-4 month rifampicin alone.

Adherence in Adolescent and Young Adult Kidney Transplant Recipients

Poor adherence to immunosuppressive medications may be the most important barrier to long term graft survival. An understanding of medication adherence and its determinants is critical to addressing this important problem. In this paper, we will review the different ways in which adherence may be compromised, summarize the evidence that young people constitute a particularly high risk group, and consider the consequences and impact of poor adherence. We will also review the determinants of adherence, including characteristics of the patient and family, the treatment regimen, the healthcare team and its organization, and the healthcare system. We will highlight the most common barriers to adherence identified by young people, and consider different methods of measuring adherence, along with the advantages and limitations of each. Finally, we will consider possible intervention strategies to improve adherence in young people.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.

Reminder systems to improve patient adherence to tuberculosis clinic appointments for diagnosis and treatment

BACKGROUND

People with active tuberculosis (TB) require six months of treatment. Some people find it difficult to complete treatment, and there are several approaches to help ensure completion. One such system relies on reminders, where the health system prompts patients to attend for appointments on time, or re-engages people who have missed or defaulted on a scheduled appointment.

OBJECTIVES

To assess the effects of reminder systems on improving attendance at TB diagnosis, prophylaxis, and treatment clinic appointments, and their effects on TB treatment outcomes.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, Cochrane Effective Practice and Organization of Care Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, CINAHL, SCI-EXPANDED, SSCI, mRCT, and the Indian Journal of Tuberculosis without language restriction up to 29 August 2014. We also checked reference lists and contacted researchers working in the field.

SELECTION CRITERIA

Randomized controlled trials (RCTs), including cluster RCTs and quasi-RCTs, and controlled before-and-after studies comparing reminder systems with no reminders or an alternative reminder system for people with scheduled appointments for TB diagnosis, prophylaxis, or treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias in the included trials. We compared the effects of interventions by using risk ratios (RR) and presented RRs with 95% confidence intervals (CIs). Also we assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

Nine trials, including 4654 participants, met our inclusion criteria. Five trials evaluated appointment reminders for people on treatment for active TB, two for people on prophylaxis for latent TB, and four for people undergoing TB screening using skin tests. We classified the interventions into 'pre-appointment' reminders (telephone calls or letters prior to a scheduled appointment) or 'default' reminders (telephone calls, letters, or home visits to people who had missed an appointment).For people being treated for active TB, clinic attendance and TB treatment completion were higher in people receiving pre-appointment reminder phone-calls (clinic attendance: 66% versus 50%; RR 1.32, 95% CI 1.10 to 1.59, one trial (USA), 615 participants, low quality evidence; TB treatment completion: 100% versus 88%; RR 1.14, 95% CI 1.02 to 1.27, one trial (Thailand), 92 participants, low quality evidence). Clinic attendance and TB treatment completion were also higher with default reminders (letters or home visits) (clinic attendance: 52% versus 10%; RR 5.04, 95% CI 1.61 to 15.78, one trial (India), 52 participants, low quality evidence; treatment completion: RR 1.17, 95% CI 1.11 to 1.24, two trials (Iraq and India), 680 participants, moderate quality evidence).For people on TB prophylaxis, clinic attendance was higher with a policy of pre-appointment phone-calls (63% versus 48%; RR 1.30, 95% CI 1.07 to 1.59, one trial (USA), 536 participants); and attendance at the final clinic was higher with regular three-monthly phone-calls or nurse visits (93% versus 65%, one trial (Spain), 318 participants).For people undergoing screening for TB, three trials of pre-appointment phone-calls found little or no effect on the proportion of people returning to clinic for the result of their skin test (three trials, 1189 participants, low quality evidence), and two trials found little or no effect with take home reminder cards (two trials, 711 participants). All four trials were conducted among healthy volunteers in the USA.

AUTHORS' CONCLUSIONS

Policies of sending reminders to people pre-appointment, and contacting people who miss appointments, seem sensible additions to any TB programme, and the limited evidence available suggests they have small but potentially important benefits. Future studies of modern technologies such as short message service (SMS) reminders would be useful, particularly in low-resource settings.

Helping our patients take HIV pre-exposure prophylaxis (PrEP): a systematic review of adherence interventions

OBJECTIVES

Adherence is critical for maximizing the effectiveness of pre-exposure prophylaxis (PrEP) in preventing HIV infection. Strategies for promoting adherence to HIV treatment, and their potential application to PrEP adherence, have received considerable attention. However, adherence promotion strategies for prevention medications have not been well characterized and may be more applicable to PrEP. We aimed to identify adherence support interventions that have been effective in other prevention fields and could be applied in the HIV prevention context to support pill taking among PrEP users.

METHODS

To identify adherence support interventions that could be evaluated and applied in the PrEP context, we conducted a systematic review across the following prevention fields: hypertension, latent tuberculosis infection, hyperlipidaemia, oral contraceptives, osteoporosis, malaria prophylaxis, and post-exposure prophylaxis for HIV infection. We included randomized controlled trials that evaluated the efficacy of interventions to improve adherence to daily oral medications prescribed for primary prevention in healthy individuals or for secondary prevention in asymptomatic individuals.

RESULTS

Our searches identified 585 studies, of which 48 studies met the eligibility criteria and were included in the review; nine evaluated multiple strategies, yielding 64 separately tested interventions. Interventions with the strongest evidence for improving adherence included complex, resource-intensive interventions, which combined multiple adherence support approaches, and low-cost, low-intensity interventions that provided education or telephone calls for adherence support.

CONCLUSIONS

Our review identified adherence interventions with strong evidence of efficacy across prevention fields and provides recommendations for evaluating these interventions in upcoming PrEP studies.

Old and new approaches to diagnosing and treating latent tuberculosis in children in low-incidence countries

PURPOSE OF REVIEW

The primary purpose is to review guidance on the testing and treatment of latent tuberculosis infection (LTBI) in children. Most children and adults with LTBI have positive tuberculin skin test (TST) or interferon gamma release assay (IGRA) results, normal examinations, and normal chest radiographs. Diagnosis of and treatment completion for LTBI are critical to diminish future cases of tuberculosis (TB) disease.

RECENT FINDINGS

Children should be screened for TB risk factors, and only children with risk factors should be tested with either a TST or an IGRA. IGRAs measure interferon gamma production by lymphocytes after they are stimulated ex vivo by antigens that are primarily Mycobacterium tuberculosis-specific. The foundation of LTBI therapy in the United States has been 9 months of daily isoniazid, but shorter treatment regimens now exist, including a 12-dose regimen of weekly isoniazid and rifapentine. These shorter regimens are associated with higher completion rates.

SUMMARY

There are two distinct modalities for LTBI diagnosis and several treatment regimens that can prevent TB disease in infected children. The selection of treatment regimen should take several factors into consideration, including adherence, drug susceptibility results of the presumed source case (if known), safety, cost, and patient preference.

Interventions to increase medication adherence in African-American and Latino populations: a literature review

The objective of this systematic review was to investigate the effectiveness of interventions to improve medication adherence in ethnic minority populations. A literature search from January 2000 to August 2012 was conducted through PubMed/Medline, Web of Science, The Cochrane Library, and Google Scholar. Search terms used included: medication (MeSH), adherence, medication adherence (MeSH), compliance (MeSH), persistence, race, ethnicity, ethnic groups (MeSH), minority, African-American, Hispanic, Latino, Asian, Pacific Islander, and intervention. Studies which did not have ≥75% of the sample population comprised of individuals of any one ethnic background were excluded, unless the authors performed sub-group analyses by race/ethnicity. Of the 36 studies identified, 20 studies showed significant post-intervention differences. Sample population sizes ranged from 10 to 520, with a median of 126.5. The studies in this review were conducted with patients of mainly African-American and Latino descent. No studies were identified which focused on Asians, Pacific Islanders, or Native Americans. Interventions demonstrating mixed results included motivational interviewing, reminder devices, community health worker (CHW) delivered interventions, and pharmacist-delivered interventions. Directly observed therapy (DOT) was a successful intervention in two studies. Interventions which did not involve human contact with patients were ineffective. In this literature review, studies varied significantly in their methods and design as well as the populations studied. There was a lack of congruence among studies in the way adherence was measured and reported. No single intervention has been seen to be universally successful, particularly for patients from ethnic minority backgrounds.

A meta-analysis of cognitive-based behaviour change techniques as interventions to improve medication adherence

OBJECTIVE

To describe and evaluate the use of cognitive-based behaviour change techniques as interventions to improve medication adherence.

DESIGN

Systematic review and meta-analysis of interventions to improve medication adherence.

DATA SOURCES

Search of the MEDLINE, EMBASE, PsycINFO, CINAHL and The Cochrane Library databases from the earliest year to April 2013 without language restriction. References of included studies were also screened to identify further relevant articles.

REVIEW METHODS

We used predefined criteria to select randomised controlled trials describing a medication adherence intervention that used Motivational Interviewing (MI) or other cognitive-based techniques. Data were extracted and risk of bias was assessed by two independent reviewers. We conducted the meta-analysis using a random effects model and Hedges' g as the measure of effect size.

RESULTS

We included 26 studies (5216 participants) in the meta-analysis. Interventions most commonly used MI, but many used techniques such as aiming to increase the patient's confidence and sense of self-efficacy, encouraging support-seeking behaviours and challenging negative thoughts, which were not specifically categorised. Interventions were most commonly delivered from community-based settings by routine healthcare providers such as general practitioners and nurses. An effect size (95% CI) of 0.34 (0.23 to 0.46) was calculated and was statistically significant (p < 0.001). Heterogeneity was high with an I(2) value of 68%. Adjustment for publication bias generated a more conservative estimate of summary effect size of 0.21 (0.08 to 0.33). The majority of subgroup analyses produced statistically non-significant results.

CONCLUSIONS

Cognitive-based behaviour change techniques are effective interventions eliciting improvements in medication adherence that are likely to be greater than the behavioural and educational interventions largely used in current practice. Subgroup analyses suggest that these interventions are amenable to use across different populations and in differing manners without loss of efficacy. These factors may facilitate incorporation of these techniques into routine care.

Patient education and counselling for promoting adherence to treatment for tuberculosis

BACKGROUND

Non-adherence to tuberculosis treatment can lead to prolonged periods of infectiousness, relapse, emergence of drug-resistance, and increased morbidity and mortality. In this review, we assess whether patient education or counselling, or both, promotes adherence to tuberculosis treatment.

OBJECTIVES

To evaluate the effects of patient education or counselling, or both, on treatment completion and cure in people requiring treatment for active or latent tuberculosis.

SEARCH METHODS

Without language restriction, we searched for eligible studies in the Cochrane Infectious Diseases Group Specialized Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and LILACS; checked reference lists of relevant articles; and contacted relevant researchers and organizations up to 24 November 2011.

SELECTION CRITERIA

Randomized controlled trials examining the effects of education or counselling, or both, on treatment completion and cure in people with clinical tuberculosis; and treatment completion and clinical tuberculosis in people with latent disease.

DATA COLLECTION AND ANALYSIS

We independently screened identified studies for eligibility, assessed methodological quality, and extracted data; with differences resolved by consensus. We expressed study results as risk ratios (RRs) with 95% confidence intervals (CI).

MAIN RESULTS

We found three trials, with a total of 1437 participants, which examined the effects of different educational and counselling interventions on adherence to treatment for latent tuberculosis.All three trials reported the proportion of people who successfully completed treatment for latent tuberculosis. Overall, education or counselling interventions may increase successful treatment completion but the magnitude of benefit is likely to vary depending on the nature of the intervention, and the setting (data not pooled, 923 participants, three trials, low quality evidence).In a four-arm trial in children from Spain, counselling by nurses via telephone increased the proportion of children completing treatment from 65% to 94% (RR 1.44, 95% CI 1.21 to 1.72; 157 participants, one trial), and counselling by nurses through home visits increased completion to 95% (RR 1.46, 95% CI 1.23 to 1.74; 156 participants, one trial). Both of these interventions were superior to counselling by physicians at the tuberculosis clinic (RR 1.20, 95% CI 0.98 to 1.47; 159 participants, one trial).In the USA, a programme of peer counselling for adolescents failed to show an effect on treatment completion rates at six months (RR 1.01, 95% CI 0.90 to 1.13; 394 participants, one trial). In this trial treatment completion was around 75% even in the control group.In the third study, in prisoners from the USA, treatment completion was very low in the control group (12%), and although counselling significantly improved this, completion in the intervention group remained low at 24% (RR 1.94, 95% CI 1.03 to 3.68; 211 participants, one trial).None of these trials aimed to assess the effect of these interventions on the subsequent development of active tuberculosis, and we found no trials that assessed the effects of patient education or counselling on adherence to treatment for active tuberculosis.

AUTHORS' CONCLUSIONS

Educational or counselling interventions may improve completion of treatment for latent tuberculosis. As would be expected, the magnitude of the benefit is likely to depend on the nature of the intervention, and the reasons for low completion rates in the specific setting.

Psychological interventions for headache in children and adolescents

Headache in children and adolescents represents a number of complex and multifaceted pain syndromes that can benefit from psychological intervention. There is good evidence for the efficacy of cognitive behavioral therapy, relaxation training, and biofeedback. The choice of intervention is influenced by patients' age, sex, family and cultural background, as well as the nature of stressors and comorbid psychiatric symptoms. Management must always be family-centered. Psychological treatments are essential elements of the multidisciplinary, biopsychosocial management of primary headache disorders, particularly for those with frequent or chronic headache, a high level of headache-related disability, medication overuse, or comorbid psychiatric symptoms. Future studies of efficacy and effectiveness of psychological treatment should use the International Headache Society's definition and classification of headache disorders, and stratify results by headache type, associated conditions, and treatment modality.

Treatment outcomes and medication compliance for children and adolescents, 30 days post-discharge from an in-patient psychiatric hospital

A variety of authors have suggested that children and adolescents are at risk for serious adverse health outcomes because of a lack of compliance with medication regimens. A lack of compliance includes taking less or more medication than prescribed, and taking medication at the wrong times. One study that examined the medication compliance of 81 students who were 10 years of age or older, and were enrolled in a school-based health center, determined that only 45 students (56%) filled the prescription given to them by the doctor. Of those students who filled the prescription, 76% reported that they always took the medication on time, 22% reported forgetting to take the medication some of the time and 2% reported never taking the medication.

A systematic review of adherence-enhancing interventions in adolescents taking long-term medicines

PURPOSE

To assess the effectiveness of adherence-enhancing interventions (AEIs) aimed at adolescents (10-19-year-olds).

METHODS

An extensive search of seven bibliographic databases was conducted at the end of 2009 to identify comparative studies evaluating AEIs targeting adolescents. Data describing study characteristics and intervention effects on adherence to medicines or health outcomes were extracted and summarized using qualitative and quantitative methods.

RESULTS

A total of 17 AEIs were identified: 12 studies (70%) were conducted in the United States, 10 (59%) included adolescents with type 1 diabetes mellitus, and 14 (82%) considered the developmental tasks of adolescence. In all, 12 AEIs successfully improved outcome measures. Features of successful interventions included targeting AEIs to a narrow age range, including family in type 1 diabetes mellitus management, and improving access to care. Poor quality and underpowered studies limit the inferences drawn from this review.

CONCLUSIONS

More diverse and robust studies are needed to identify strategies to help adolescents manage medicines.

Tuberculosis: evidence review for newly arriving immigrants and refugees

BACKGROUND

The foreign-born population bears a disproportionate health burden from tuberculosis, with a rate of active tuberculosis 20 times that of the non-Aboriginal Canadian-born population, and could therefore benefit from tuberculosis screening programs. We reviewed evidence to determine the burden of tuberculosis in immigrant populations, to assess the effectiveness of screening and treatment programs for latent tuberculosis infection, and to identify potential interventions to improve effectiveness.

METHODS

We performed a systematic search for evidence of the burden of tuberculosis in immigrant populations and the benefits and harms, applicability, clinical considerations, and implementation issues of screening and treatment programs for latent tuberculosis infection in the general and immigrant populations. The quality of this evidence was assessed and ranked using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation).

RESULTS

Chemoprophylaxis with isoniazid is highly efficacious in decreasing the development of active tuberculosis in people with latent tuberculosis infection who adhere to treatment. Monitoring for hepatotoxicity is required at all ages, but close monitoring is required in those 50 years of age and older. Adherence to screening and treatment for latent tuberculosis infection is poor, but it can be increased if care is delivered in a culturally sensitive manner.

INTERPRETATION

Immigrant populations have high rates of active tuberculosis that could be decreased by screening for and treating latent tuberculosis infection. Several patient, provider and infrastructure barriers, poor diagnostic tests, and the long treatment course, however, limit effectiveness of current programs. Novel approaches that educate and engage patients, their communities and primary care practitioners might improve the effectiveness of these programs.

Adherence to oral chemotherapy in childhood acute lymphoblastic leukemia: an evolutionary concept analysis

PURPOSE/OBJECTIVES

To clarify the concept of adherence to daily oral chemotherapy in children with acute lymphoblastic leukemia (ALL), to examine its implications for clinical practice, and to provide a foundation for further research and knowledge development.

DATA SOURCES

Published literature identified through the MEDLINE®, CINAHL®, PsycINFO, and ERIC databases.

DATA SYNTHESIS

Identified attributes of adherence to oral chemotherapy in childhood ALL included motivation, persistence, collaboration, mindfulness, cognitive capacity, flexibility, active participation, and identification of key participants in the process. Identified antecedents included a diagnosis of leukemia, the perceived value of adherence, and patient, family, and healthcare system-related factors. Identified consequences included the potential for maintaining optimal drug levels and improving disease outcome, as well as increased patient and caregiver esteem through active participation in the process. Adherence in the context of childhood ALL is defined as the active self-care behavior of taking (or having the responsibility for administering) daily oral chemotherapy, in collaboration with and according to the instructions of the healthcare provider over a defined, prolonged treatment period.

CONCLUSIONS

Adherence to oral chemotherapy in childhood ALL is a complex, multidimensional behavior that involves not only a willingness to follow the prescribed regimen over a prolonged period, but also the cognitive capacity and psychomotor skills to carry out the process.

IMPLICATIONS FOR NURSING

Nurses should recognize the importance of clear communication of medication instructions, reinforcement of adherence-related behaviors, and assistance with common issues such as pill-swallowing skills and reminder systems in caring for children with ALL.

Adherence to antibiotic prophylaxis in children with vesicoureteral reflux

Vesicoureteral reflux (VUR) affects approximately 1% of children and may predispose a child with a bladder infection to develop pyelonephritis and renal scarring. To prevent these potential sequelae, one accepted treatment option for VUR includes low-dose continuous antibiotic prophylaxis (CAP) to maintain urine sterility until the condition resolves. Despite the widespread use of CAP, little data exists regarding adherence to long-term antibiotic therapy. Not only will poor adherence to CAP potentially preclude the intended benefit, but also nonadherence with antibiotic regimens may carry untoward effects including unnecessary treatment changes for presumed antibiotic failure, emergence of resistant organisms, and compromised clinical trial outcomes. We present an overview of medication adherence in children with VUR, discuss possible consequences of nonadherence to antibiotic prophylaxis, and suggest ways to improve adherence. We raise awareness of issues related to nonadherence relevant to healthcare providers, investigators, and the community.

Review of Adherence-Related Issues in Adolescents and Young Adults With Cancer

Purpose

This review aims to provide a broad overview of the issues and clinical challenges of nonadherence in adolescents and young adults (AYAs) with cancer. Nonadherence can reduce treatment efficacy, which places the patient at higher risk of relapse, adverse effects, and poor outcomes.

Design

A review of the English-speaking literature between 1980 and 2008 was conducted to identify relevant publications, which were supplemented by reference and author searches.

Results

Definition and measurement of adherence varies. Most studies have not clearly delineated an AYA age group (ie, 15-25 years) and have been dominated by leukemia and lymphoma samples. Estimates for nonadherence in this population range from 27% to 60%, with openness of family relationships and support found to predict adherence. Strategies to avoid, assess, and manage nonadherence are presented.

Conclusion

Overall, the evidence base for adherence and strategies to promote it in AYAs with cancer is woefully lacking. There is a need for high-quality studies that target clinically important questions, randomized controlled trials of theoretically based interventions, and development and evaluation of training programs for oncology staff in the special issues faced by AYAs with cancer.

Evaluation of a school-based program for diagnosis and treatment of latent tuberculosis infection in immigrant children

OBJECTIVE

To evaluate a 10-year school-based latent tuberculosis infection (LTBI) screening program, targeting immigrant children in Montreal, Canada, and to identify predictive factors for refusal and, poor adherence to treatment.

METHODS

Immigrant children were screened for LTBI with Tuberculin Skin Test (TST). Isoniazid was, given when LTBI was diagnosed. Predictors of LTBI, of refusal of follow-up and treatment and of poor, adherence to isoniazid were analyzed.

RESULTS

Four thousand three hundred and seventy-five children were offered screening, 82.3% consented to TST and 22.8% were positive. An, older age at migration (odds ratio (OR)=1 [95% CI: 1.0-1.01]), as well as migration from a none, established market economy country (OR varying from 2.41 to 4.23) were significantly associated with, positive TST. Among positive children, further evaluation was refused in 5.7%, mainly in migrants from, Eastern Europe (OR=4.05 [95% CI: 2.14-7.69]). Refusal of treatment (11.2%) was more frequent in, Eastern European when compared to South-eastern Asian (OR=6.91 [95% CI: 1.56-30.75]), in, blended families (OR=3.25 [95% CI: 1.25-8.46]) and when the first visit to hospital was delayed (OR=1.01 [95% CI: 1.0-1.02]). Adequate completion of treatment was noted in 61.3%. Age>16 years (OR=1.82 [95% CI: 1.82-2.99]), a delay between TST and first visit>15 days (OR=1.6 [95% CI: 1.12-2.28]), as well as the presence of relative>18 years in the household (OR=1.56 [95% CI: 1.0-2.43]), were associated with poor adherence to treatment.

CONCLUSION

Sociocultural and behavioural factors are involved in acceptance of LTBI treatment in, immigrant children. Adherence to treatment is challenging and requires comperhension of sociocultural beliefs and accessibility to TB clinic.

The reliability and practicality of the Arkansas method assay of isoniazid adherence

The Arkansas method (AM) for isoniazid (INH) metabolite detection is a relatively inexpensive, simple, objective measure of adherence. The purpose of the study was to explore whether variations in urine sample handling and storage will produce accurate assay outcomes. Participants were a convenience sample of 28 adults and adolescents prescribed INH for latent tuberculosis infection. Participants provided one sample to test effects of the following: mixing processes; durations at room temperature, in a refrigerator, or frozen; and effects of freeze/thaw cycles on AM outcomes. No manipulations had a discernible impact on outcomes with concordant positive rates from 85% to 100%. Concordance rates of manipulated samples did not appear to differ from rates of norm samples. Results suggest that urine samples can withstand a variety of manipulations in both handling and storage without affecting the accuracy of AM assay results. These findings have important implications for providers of treatment and researchers and provide the impetus for both to examine the potential of using the AM of INH metabolite testing as a measure of medication adherence.

Placebo interventions for all clinical conditions

BACKGROUND

Placebo interventions are often claimed to substantially improve patient-reported and observer-reported outcomes in many clinical conditions, but most reports on effects of placebos are based on studies that have not randomised patients to placebo or no treatment. Two previous versions of this review from 2001 and 2004 found that placebo interventions in general did not have clinically important effects, but that there were possible beneficial effects on patient-reported outcomes, especially pain. Since then several relevant trials have been published.

OBJECTIVES

Our primary aims were to assess the effect of placebo interventions in general across all clinical conditions, and to investigate the effects of placebo interventions on specific clinical conditions. Our secondary aims were to assess whether the effect of placebo treatments differed for patient-reported and observer-reported outcomes, and to explore other reasons for variations in effect.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 4, 2007), MEDLINE (1966 to March 2008), EMBASE (1980 to March 2008), PsycINFO (1887 to March 2008) and Biological Abstracts (1986 to March 2008). We contacted experts on placebo research, and read references in the included trials.

SELECTION CRITERIA

We included randomised placebo trials with a no-treatment control group investigating any health problem.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Trials with binary data were summarised using relative risk (a value of less than 1 indicates a beneficial effect of placebo), and trials with continuous outcomes were summarised using standardised mean difference (a negative value indicates a beneficial effect of placebo).

MAIN RESULTS

Outcome data were available in 202 out of 234 included trials, investigating 60 clinical conditions. We regarded the risk of bias as low in only 16 trials (8%), five of which had binary outcomes.In 44 studies with binary outcomes (6041 patients), there was moderate heterogeneity (P < 0.001; I(2) 45%) but no clear difference in effects between small and large trials (symmetrical funnel plot). The overall pooled effect of placebo was a relative risk of 0.93 (95% confidence interval (CI) 0.88 to 0.99). The pooled relative risk for patient-reported outcomes was 0.93 (95% CI 0.86 to 1.00) and for observer-reported outcomes 0.93 (95% CI 0.85 to 1.02). We found no statistically significant effect of placebo interventions in four clinical conditions that had been investigated in three trials or more: pain, nausea, smoking, and depression, but confidence intervals were wide. The effect on pain varied considerably, even among trials with low risk of bias.In 158 trials with continuous outcomes (10,525 patients), there was moderate heterogeneity (P < 0.001; I(2) 42%), and considerable variation in effects between small and large trials (asymmetrical funnel plot). It is therefore a questionable procedure to pool all the trials, and we did so mainly as a basis for exploring causes for heterogeneity. We found an overall effect of placebo treatments, standardised mean difference (SMD) -0.23 (95% CI -0.28 to -0.17). The SMD for patient-reported outcomes was -0.26 (95% CI -0.32 to -0.19), and for observer-reported outcomes, SMD -0.13 (95% CI -0.24 to -0.02). We found an effect on pain, SMD -0.28 (95% CI -0.36 to -0.19)); nausea, SMD -0.25 (-0.46 to -0.04)), asthma (-0.35 (-0.70 to -0.01)), and phobia (SMD -0.63 (95% CI -1.17 to -0.08)). The effect on pain was very variable, also among trials with low risk of bias. Four similarly-designed acupuncture trials conducted by an overlapping group of authors reported large effects (SMD -0.68 (-0.85 to -0.50)) whereas three other pain trials reported low or no effect (SMD -0.13 (-0.28 to 0.03)). The pooled effect on nausea was small, but consistent. The effects on phobia and asthma were very uncertain due to high risk of bias. There was no statistically significant effect of placebo interventions in the seven other clinical conditions investigated in three trials or more: smoking, dementia, depression, obesity, hypertension, insomnia and anxiety, but confidence intervals were wide.Meta-regression analyses showed that larger effects of placebo interventions were associated with physical placebo interventions (e.g. sham acupuncture), patient-involved outcomes (patient-reported outcomes and observer-reported outcomes involving patient cooperation), small trials, and trials with the explicit purpose of studying placebo. Larger effects of placebo were also found in trials that did not inform patients about the possible placebo intervention.

AUTHORS' CONCLUSIONS

We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

Meta-analysis of factors related to health services that predict treatment default by tuberculosis patients

The identification of factors that predict tuberculosis (TB) treatment default can help control this problem. The current study used a systematic review to investigate associations between TB treatment default and previously studied factors related to health services. Abstracts were searched in the MEDLINE and LILACS databases and in the bibliography of the full texts under evaluation. Studies were included if TB treatment default was evaluated by comparing two or more groups and data could be extracted. A total of 41 studies were included for combining data. It was possible to combine five exposures: "difficult access to health services"; "need for hospitalization"; "training or support for adherence"; "delay in initiating treatment"; "long wait before medical attendance". "Difficult access to health services", "training or support for adherence", and "need for hospitalization" were associated with TB treatment default. All exposures demonstrated heterogeneity, which was only explained in one. Publication bias was only detected for one exposure.

Multi-level barriers to LTBI treatment: a research note

Background This study describes the barriers to effective and timely LTBI treatment encountered in a research study on INH adherence in Latino adolescents. Method Participant study logs were reviewed, results of continuing medical education pretests for medical providers were examined, and participating medical facilities were contacted in order to construct a profile of multi-level barriers to LTBI treatment. Results A total of 285 TST positive Latino (96%) high school students were recruited into the trial. We encountered a lack of understanding of the gravity of tuberculosis infection among both the public and providers of health care. Parents and adolescents cited competing priorities, transportation problems and financial constraints as reasons for non-compliance. Discussion Improved education of the public and physicians is needed regarding the gravity of the disease and the value of treatment, as well as public and financial support for LTBI treatment by both the government and the medical community.

Reminder systems and late patient tracers in the diagnosis and management of tuberculosis

BACKGROUND

Reminder systems and late patient tracers as strategies to improve patients' adherence to tuberculosis screening, diagnosis, and treatment are used in some countries, but their effectiveness has not previously been systematically reviewed.

OBJECTIVES

To assess the effects of reminder systems and late patient tracers on completion of diagnostics, commencement of treatment in people referred for curative or prophylactic treatment of tuberculosis, completion of treatment in people starting curative or prophylactic treatment for tuberculosis, and cure in people being treated for active tuberculosis.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group Specialized Register (June 2008), Cochrane Effective Practice and Organization of Care Group Specialized Register (April 2007), CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE (1966 to June 2008), EMBASE (1974 to June 2008), LILACS (1982 to June 2008), CINAHL (1982 to June 2008), SCI-EXPANDED (1945 to June 2008), SSCI (1956 to June 2008), mRCT (June 2008), Indian Journal of Tuberculosis (1983 to June 2008), and reference lists. We also contacted researchers working in the field.

SELECTION CRITERIA

Randomized controlled trials (RCTs), including cluster RCTs and quasi-RCTs, and controlled before-and-after studies comparing any reminders or late patient tracers with no or other kinds of reminders or late patient tracers. We included people in any setting who require treatment for tuberculosis or require prophylaxis against tuberculosis and are referred to tuberculosis diagnostic or screening services.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial risk of bias and extracted data. No meta-analysis could be undertaken due to the heterogeneity of interventions across trials.

MAIN RESULTS

Nine trials involving 5257 participants met the inclusion criteria. Three assessed the use of late patient tracers, and six assessed reminder systems. Late patient tracers (home visit and letter) were shown to be beneficial in increasing adherence to tuberculosis treatment compared with no late patient tracer. The results from almost all the reminder trials, except one, show benefits of different types of reminders compared to no reminder on adherence to tuberculosis clinic appointments.

AUTHORS' CONCLUSIONS

The included trials show significantly better outcomes among those tuberculosis patients for which late patient tracers and reminders are used. Studies of good quality (large and with rigorous study design) are needed to decide the most effective late patient tracer actions and reminders in different settings. Future studies of reminders in chemoprophylaxis and treatment settings would be useful.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

MAIN RESULTS

For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 81 interventions reported in 69 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

AUTHORS' CONCLUSIONS

For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Meta-analysis of psychological interventions to promote adherence to treatment in pediatric chronic health conditions

OBJECTIVE

To estimate the effectiveness of adherence-promoting psychological interventions for pediatric populations with chronic health conditions.

METHODS

A meta-analysis was conducted on 70 adherence-promoting psychological intervention studies among chronically ill youth using a weighted least squares approach and random effect model.

RESULTS

Medium effects sizes were found for the behavioral (mean d =.54, 95% confidence interval [CI] = 0.34-0.73, n = 10) and multi-component interventions (mean d =.51, 95% CI = 0.45-0.57, n = 46), while educational interventions displayed a small effect size with adherence (mean d =.16, 95% CI = 0.10-0.22, n = 23). Study designs incorporating pre-post comparisons yielded effect sizes approaching the medium range (mean d =.42, 95% CI = 0.36-0.48, n = 30).

CONCLUSIONS

Behavioral and multi-component interventions appear to be relatively potent in promoting adherence among chronically ill youth. Recommendations for future research and methodological issues are presented.

Predictors of adherence to latent tuberculosis infection therapy in Latino immigrants

Adherence to Latent Tuberculosis Infection (LTBI) therapy is a continuing community problem. The purpose of this study was to examine the predictors of adherence to LTBI therapy in Latino immigrants at a public health clinic. A descriptive study was conducted to examine 153 randomly selected records from a population of Latino immigrant clients who had received a recommendation for 9 months of Isoniazid (INH) therapy. Most of the clients were women (64%), the mean age was 26.1, and the mean time in the U.S. was 4.58 years. The majority came from El Salvador, Bolivia, or Guatemala. Adherence dropped off in a linear fashion from month 1 (84%) to month 8 (34%). None of the demographic factors predicted adherence. Implications for community health nursing are discussed.

Patient empowerment in tuberculosis control: reflecting on past documented experiences

OBJECTIVES

To review the available published and non-published literature on patient empowerment in tuberculosis (TB) control, describe what it entails, identify possible trends and conclusions, and suggest areas both for informing policy makers and for orienting further research.

METHODS

We searched MEDLINE and PSYCINFO databases, used World Wide Web research tools and included conference abstracts and specific project reports.

RESULTS

Experience shows that operational definitions, potential barriers towards empowerment and contextual issues need to be considered. Four types of experiences were reported: (1) enabling patients to take more responsibility for their health, especially regarding adherence to treatment, (2) organizing TB patients into groups and clubs, (3) building patient-centred care in TB and general health services, and (4) using TB patients' advocacy skills to improve TB control.

CONCLUSION

Patient empowerment conceptions through interventions and studies should primarily involve TB patients themselves. Patients' activism--their role, the shape it takes and resulting effects--is insufficiently documented.

Costs and cost-effectiveness of adolescent compliance with treatment for latent tuberculosis infection: results from a randomized trial

PURPOSE

Assess the costs and cost-effectiveness of an incentive-based tuberculosis (TB) program designed to promote adolescents' compliance with treatment for latent TB infection (LTBI).

METHODS

Randomized controlled trial. Adolescents between the ages of 11 and 19 years who were referred to one of two participating clinics after being screened for TB and receiving a positive diagnosis indicating LTBI (n = 794) were assigned to one of four groups: usual care, peer counseling, contingency contracting, and combined peer counseling/contingency contracting. Primary outcome variables were completion of isoniazid preventive therapy (IPT), total treatment costs, and lifetime TB-related costs per quality-adjusted life year (QALY) in each of the four study groups (three treatment, one control). Cost effectiveness was evaluated using a five-stage Markov model and a Monte Carlo simulation with 10,000 trials.

RESULTS

Average costs were 199 dollars for usual care (UC), 277 dollars for peer counseling (PC), 326 dollars for contingency contracting (CC), and 341 dollars for PC + CC combined. The differences among these groups were all significant at the p = .001 level. Only the PC + CC group improved the rate of IPT completion (83.8%) relative to usual care (75.9%) (p = .051), with an overall incremental CE ratio of 209 dollars per QALY relative to usual care.

CONCLUSION

Incentives combined with peer counseling are a cost-effective strategy for helping adolescents to complete care when combined with peer counseling.

Knowledge, attitudes, and practices regarding antibiotic use among Latinos in the United States: review and recommendations

Inappropriate use of antibiotics contributes to antimicrobial resistance worldwide. In Latin America, antibiotics are easily obtained over the counter. In the United States, the Latino population is the largest and fastest growing immigrant group. Hence, it is necessary to understand Latino cultural practices in regards to antibiotic use to develop effective interventions that reduce inappropriate antibiotic use among this population. We conducted a systematic review of descriptive and intervention studies measuring knowledge, attitudes, and practices of antibiotic use among Latinos in the United States. The search yielded only 11 descriptive studies and no interventions. The literature suggests that many Latinos in the United States self-prescribe antibiotics because of financial and sociocultural barriers and inaccurately believe that antibiotics help treat viral infections. Increased access to health care and appropriate culturally tailored interventions specific to Latinos are needed to promote judicious antibiotic use among Latinos.

Coaching Process Outcomes of a Family Visit Nutrition and Physical Activity Intervention

The purpose of this article is to report the process outcomes of a coaching methodology used in a study designed to increase fruit and vegetable consumption and physical activity in families. Eighty-eight families with second graders were recruited from a rural, biethnic community in Colorado and randomized to intervention and delayed intervention conditions. This article reports on the 27 families in the delayed intervention group. Families received up to 10 home visits over 10 months from a family advisor and completed activities to improve their dietary and physical activity behaviors. Coaching conversations took place during each home visit. Coaching process outcomes were evaluated by analysis of visit documentation, participant survey, and qualitative interviews. Results indicated that coaching, in conjunction with family activities, engaged families in the process of change and facilitated movement toward the achievement of their weekly nutrition or physical activity goals. Coaching methodology may be particularly useful for participatory research.

A multidimensional integrative medicine intervention to improve cardiovascular risk

BACKGROUND

Integrative medicine is an individualized, patient-centered approach to health, combining a whole-person model with evidence-based medicine. Interventions based in integrative medicine theory have not been tested as cardiovascular risk-reduction strategies. Our objective was to determine whether personalized health planning (PHP), an intervention based on the theories and principles underlying integrative medicine, reduces 10-year risk of coronary heart disease (CHD).

METHODS

We conducted a randomized, controlled trial among 154 outpatients age 45 or over, with 1 or more known cardiovascular risk factors. Subjects were enrolled from primary care practices near an academic medical center, and the intervention was delivered at a university Center for Integrative Medicine. Following a health risk assessment, each subject in the intervention arm worked with a health coach and a medical provider to construct a personalized health plan. The plan identified specific health behaviors important for each subject to modify; the choice of behaviors was driven both by cardiovascular risk reduction and the interests of each individual subject. The coach then assisted each subject in implementing her/his health plan. Techniques used in implementation included mindfulness meditation, relaxation training, stress management, motivational techniques, and health education and coaching. Subjects randomized to the comparison group received usual care (UC) without access to the intervention. Our primary outcome measure was 10-year risk of CHD, as measured by a standard Framingham risk score, and assessed at baseline, 5, and 10 months. Differences between arms were assessed by linear mixed effects modeling, with time and study arm as independent variables.

RESULTS

Baseline 10-year risk of CHD was 11.1% for subjects randomized to UC (n=77), and 9.3% for subjects randomized to PHP (n=77). Over 10 months of the intervention, CHD risk decreased to 9.8% for UC subjects and 7.8% for intervention subjects. Based on a linear mixed-effects model, there was a statistically significant difference in the rate of risk improvement between the 2 arms (P=.04). In secondary analyses, subjects in the PHP arm were found to have increased days of exercise per week compared with UC (3.7 vs 2.4, P=.002), and subjects who were overweight on entry into the study had greater weight loss in the PHP arm compared with UC (P=.06).

CONCLUSIONS

A multidimensional intervention based on integrative medicine principles reduced risk of CHD, possibly by increasing exercise and improving weight loss.