Digital Health Technologies to Improve Medication Adherence and Treatment Outcomes in Patients With Tuberculosis: Systematic Review of Randomized Controlled Trials

Evaluation of usability and user feedback to guide telepharmacy application development in Indonesia: a mixed-methods study

BACKGROUND

In Indonesia, the adoption of telepharmacy was propelled by the COVID-19 pandemic, prompting the need for a user-friendly application to support both the general population and pharmacists in accessing healthcare services. Therefore, this study aimed to evaluate usability and user feedback of a pioneering telepharmacy application known as Tanya Obat (translating to "Ask about Medications") in Indonesia, from the perspectives of the general population and pharmacists.

METHODS

A mixed-methods sequential study was conducted with the early-stage Tanya Obat application in Bandung City. Participants, including the general population and pharmacists, were instructed to use the application for a week. Questionnaires for the general population and pharmacists were distributed from March to May and February to June 2023, respectively. The System Usability Scale questionnaire was adopted to describe usability of the developed application. Further exploration of the quantitative results required collecting open-ended feedback to assess the impressions of the participants, difficulties encountered, and desired features for enhanced user-friendliness. The collected statements were summarized and clustered using thematic analysis. Subsequently, the association between the characteristics of participants and perceived usability was determined with the Chi-square test.

RESULT

A total of 176 participants, comprising 100 individuals from the general population and 76 pharmacists, engaged in this study. In terms of usability, the questionnaire showed that Tanya Obat application was on the borderline of acceptability, with mean scores of 63.4 and 64.1 from the general population and pharmacists, respectively. Additionally, open-ended feedback targeted at achieving a more compelling user experience was categorized into two themes, including concerns regarding the functionality of certain features and recommendations for improved visual aesthetics and bug fixes. No significant associations were observed between the characteristics of participants and perceived usability (p-value > 0.05).

CONCLUSION

The results showed that the perceived usability of Tanya Obat developed for telepharmacy was below average. Therefore, feature optimizations should be performed to facilitate usability of this application in Indonesia.

Evaluating Treatment Outcomes and Tuberculosis Infection Risks: A Comparative Study of Centralized Hospitalization vs. Home-Based Treatment

Background: Guizhou Province in Southwest China has experimented with a centralized hospitalization (CH) treatment for active and severe cases of pulmonary tuberculosis (PTB). The objective of this study was to compare treatment outcomes of patients with tuberculosis (TB) receiving care in a CH setting with those receiving home-based (HB) care. In addition, this study aimed to assess the probability of their household contacts contracting tuberculosis infection. Method: A retrospective review of medical records was undertaken for patients with TB who completed their treatment in four counties in Guizhou, China, spanning from January 2022 to August 2023. In addition, a cross-sectional survey was conducted on the tuberculin skin test (TST) among household contacts of new patients with TB who had completed their treatment. Results: In the retrospective study, 94.8% had successful CH treatment, and 93.1% had successful HB treatment (p value = 0.70). In the prospective study, 559 and 448 household contacts of patients receiving CH treatment had 16 positive and 89 negative TST results, whereas those with HB treatment showed 26 positive and 74 negative TST results. Regarding a logistic regression analysis, the CH group was nearly two times more likely to test negative on the TST, 1.95 (95% CI: 0.98, 3.92). After adjusting for confounding variables, the odds ratio increased significantly to 4.42 (95% CI: 1.22, 16.04). Conclusions: CH for treatment of TB did not show superior success rates, but it may reduce the risk of transmitting tuberculosis infection to household contacts compared to home treatment.

Exploring opportunities to strengthen rural tuberculosis health service delivery: a qualitative study with health workers in Tibet autonomous region, China

OBJECTIVES

This qualitative study aimed to explore opportunities to strengthen tuberculosis (TB) health service delivery from the perspectives of health workers providing TB care in Shigatse prefecture of Tibet Autonomous Region, China.

DESIGN

Qualitative research, semi-structured in-depth interviews.

SETTING

The TB care ecosystem in Shigatse, including primary and community care.

PARTICIPANTS

Participants: 37 semi-structured interviews were conducted with village doctors (14), township doctors and nurses (14), county hospital doctors (7) and Shigatse Centre for Disease Control staff (2).

RESULTS

The three main themes reported include (1) the importance of training primary and community health workers to identify people with symptoms of TB, ensure TB is diagnosed and link people with TB to further care; (2) the need to engage community health workers to ensure retention in care and adherence to TB medications; and (3) the opportunity for innovative technologies to support coordinated care, retention in care and adherence to medication in Shigatse.

CONCLUSIONS

The quality of TB care could be improved across the care cascade in Tibet and other high-burden, remote settings by strengthening primary care through ongoing training, greater support and inclusion of community health workers and by leveraging technology to create a circle of care. Future formative and implementation research should include the perspectives of health workers at all levels to improve care organisation and delivery.

New Approach to Equitable Intervention Planning to Improve Engagement and Outcomes in a Digital Health Program: Simulation Study

BACKGROUND

Digital health programs provide individualized support to patients with chronic diseases and their effectiveness is measured by the extent to which patients achieve target individual clinical outcomes and the program's ability to sustain patient engagement. However, patient dropout and inequitable intervention delivery strategies, which may unintentionally penalize certain patient subgroups, represent challenges to maximizing effectiveness. Therefore, methodologies that optimize the balance between success factors (achievement of target clinical outcomes and sustained engagement) equitably would be desirable, particularly when there are resource constraints.

OBJECTIVE

Our objectives were to propose a model for digital health program resource management that accounts jointly for the interaction between individual clinical outcomes and patient engagement, ensures equitable allocation as well as allows for capacity planning, and conducts extensive simulations using publicly available data on type 2 diabetes, a chronic disease.

METHODS

We propose a restless multiarmed bandit (RMAB) model to plan interventions that jointly optimize long-term engagement and individual clinical outcomes (in this case measured as the achievement of target healthy glucose levels). To mitigate the tendency of RMAB to achieve good aggregate performance by exacerbating disparities between groups, we propose new equitable objectives for RMAB and apply bilevel optimization algorithms to solve them. We formulated a model for the joint evolution of patient engagement and individual clinical outcome trajectory to capture the key dynamics of interest in digital chronic disease management programs.

RESULTS

In simulation exercises, our optimized intervention policies lead to up to 10% more patients reaching healthy glucose levels after 12 months, with a 10% reduction in dropout compared to standard-of-care baselines. Further, our new equitable policies reduce the mean absolute difference of engagement and health outcomes across 6 demographic groups by up to 85% compared to the state-of-the-art.

CONCLUSIONS

Planning digital health interventions with individual clinical outcome objectives and long-term engagement dynamics as considerations can be both feasible and effective. We propose using an RMAB sequential decision-making framework, which may offer additional capabilities in capacity planning as well. The integration of an equitable RMAB algorithm further enhances the potential for reaching equitable solutions. This approach provides program designers with the flexibility to switch between different priorities and balance trade-offs across various objectives according to their preferences.

mHealth App to improve medication adherence among older adult stroke survivors: Development and usability study

Background

Effective medication adherence is vital for older adult stroke survivors, yet 20-33% cease treatment within a year post-discharge, increasing risks of recurrent strokes and mortality. A mobile health (mHealth) app could be a novel tool to improve medication adherence among stroke survivors because of its potential to increase patient empowerment. A few stroke-related apps provide information and support to stroke survivors. However, none have focused on medication adherence and documented their development and evaluation process, particularly those focused on this older population.

Objective

This study aims to design and develop a smartphone app called OASapp to improve medication adherence among older adult stroke survivors and evaluate its usability.

Methods

OASapp was developed in a three-phase development process. Phase 1 is the exploration phase (including a cross-sectional survey, a systematic review, a search for stroke apps on the app stores of Apple App Store and Google Play Store, and a nominal group technique). In phase 2, a prototype was designed based on the Health Belief Model and Technology Acceptance Model. In phase 3, Alpha and Beta testing was conducted to validate the app.

Results

Twenty-five features for inclusion in the app were collected in round one, and 14 features remained and were ranked by the participants during nominal group technique. OASapp included five core components (medication management, risk factor management, health information, communication, and stroke map). Users of OASapp were satisfied based on reports from Alpha and Beta testing. The mean Usability Metric for User Experience (UMUX) score was 71.4 points (SD 14.6 points).

Conclusion

OASapp was successfully developed using comprehensive, robust, and theory-based methods and was found to be highly accepted by users. Further research is needed to establish the clinical efficacy of the app so that it can be utilized to improve clinically relevant outcomes.

Video Directly Observed Therapy for Tuberculosis Treatment in Haitian Prisons: A Pattern of Group Adherence

Classification

Research paper.

Purpose

Haitian provincial prisons historically were strapped to provide directly observed therapy (DOT) for persons with TB (PwTB) due to healthcare understaffing. A non-governmental organization addressed this gap via correctional officer-administered video DOT (VDOT).

Approach

A 16-month, quasi-experimental trial of officer-facilitated VDOT started in March 2019 at four prisons. Officers delivered doses directly without video when VDOT was inaccessible. Healthcare staff remotely tracked VDOT adherence asynchronously. Three fully-staffed prisons were controls. Our primary objective was to measure VDOT effectiveness for PwTB who began VDOT within 2 weeks of starting treatment. Our secondary objective was to measure program reach, implementation and maintenance through July 2023.

Findings

Reach-55 PwTB on VDOT met study criteria. Effectiveness: median/mean VDOT adherence for 55 individuals enrolled in the pilot were 70.8% and 60.2% respectively. Median/mean total adherence, including doses delivered by officers, were 100% and 93.5%. Implementation: VDOT adherence varied by site but not demographic characteristics; similarity of adherence patterns between subjects within a facility was high. Nursing staff reported that adherence in controls was 100%. Correctional officers reported high comfort with the program technology. Maintenance: Since the pilot, 387 PwTB have received TB medications via VDOT in the Haitian prison system.

Originality

VDOT for PwTB in low-resource Haitian prisons enabled close monitoring and follow-up; it could expand treatment options elsewhere. Total adherence neared that in control prisons. VDOT adherence varied by treatment day predominately in a group pattern, reflecting facility-level, rather than individual-level, factors.

The trial of sending short message service multidrug-resistant tuberculosis patients in Indonesia: the chance to increase knowledge and motivation

Multidrug-Resistant Tuberculosis (MDR TB) is a threat for the future control of TB disease. In Indonesia, the success rate of MDR TB patient recovery is still very low, following the still low recovery rate of TB patients. This paper aims to discuss the trial result of message delivery containing knowledge and motivation to the MDR TB sufferers. There are about 34 MDR TB patients participating in this research. During the research, everyone received a message in their handphone or the handphone of their family members every day, contained information on medication and motivation to comply with the medication. At the end of the research, the measurement on knowledge and attitude, on the compliance with medication, and on the compliance with laboratory examinations was conducted. The results were compared with the assessment before this intervention was conducted. Out of 32 patients that managed to complete the intervention, the average means of their knowledge and attitude increased significantly. The average mean of knowledge before the intervention was 9.74 to become 10.94, and the average mean of attitude was from 7.06 to become 18.47 (P<0.05). Meanwhile, the medication compliance score and the laboratory examination compliance score also changed significantly (P<0.05). SMS delivery routinely even in a short period of time managed to change knowledge and motivation of MDR TB sufferers. To conclude, it is necessary to develop recent technology effort in order to scaling-up MDR TB patients. Existing social channels in the community must be used intensively to reduce this disease negative impact.

Impact of text reminders on pneumatic compression device (PCD) compliance in patients with breast cancer-related lymphedema

PURPOSE

Do cell phone text reminders impact the rate of compliance with pneumatic compression device (PCD) therapy among women with breast cancer-related lymphedema (BCRL)?

METHODS

A prospective, randomized, 2-group feasibility study conducted at 2 centers. Participants were adult females (≥18 years old) with unilateral BCRL who had the capability of receiving reminder text messages. All participants underwent PCD therapy. Participants were randomized 1:1 to control (no text messages) or test group (received text message reminders if the PCD had not been used for 2 consecutive days). The rate of compliance between treatment groups was the main outcome measure. Secondary outcome measures were changes in arm girth, quality of life (QOL), and symptom severity.

RESULTS

Twenty-nine participants were enrolled and randomized, 25 were available for follow-up at 60 days (14 test, 11 control). Overall, 52.2% (12/23) of all participants were completely compliant, an additional 43.5% (10/23) were partially compliant, and 1 patient (4.3%) was noncompliant. The test and control groups did not differ in device compliance. In the pooled population, weight, BMI, and arm girth were improved. Overall disease-specific QOL and symptom severity were improved. Regression analysis showed benefits were greater among participants with higher rates of compliance.

CONCLUSIONS

Automated text reminders did not improve compliance in patients with BCRL as compliance rates were already high in this patient population. Improvements in weight, BMI, arm girth, disease-specific quality of life, and symptom severity measures were observed regardless of the treatment assignment. Full compliance resulted in greater functional and QOL benefits.

TRIAL REGISTRATION

The study was registered at www.

CLINICALTRIALS

gov (NCT04432727) on June 16, 2020.

The feasibility, acceptability, and preliminary impact of real-time monitors and SMS on tuberculosis medication adherence in southwestern Uganda: Findings from a mixed methods pilot randomized controlled trial

We conducted a pilot randomized controlled trial among patients initiating treatment for drug-sensitive tuberculosis (TB). Participants received real-time electronic adherence monitors and were randomized (1:1:1) to: (i) daily SMS (reminders to TB patients and notifications to social supporters sent daily for 3 months, then triggered by late or missed dosing for 3 months); (ii) weekly SMS (reminders to TB patients and notifications to social supporters sent weekly for 3 months, then triggered by late or missed dosing for 3 months); or (iii) control (no SMS). Feasibility was mainly verified by the technical function of the intervention at Month 6. The primary outcome was percent adherence as ascertained by the real time monitor. Quantitative feasibility/acceptability data were summarized descriptively. Percentage adherence and adherence patterns were assessed and compared by linear regression models. Qualitative acceptability data was collected through interviews and analyzed using content analysis. Among 63 participants, the median age was 35 years, 75% had no regular income, and 84% were living with HIV. Feasibility was demonstrated as most of the daily [1913/2395 (80%)] and weekly [631/872 (72%)] SMS reminders to TB patients were sent successfully. Also, most of the daily [1577/2395 (66%)] and weekly [740/872 (85%)] SMS notifications to social supporters and adherence data (96%) were sent successfully. Challenges included TB status disclosure, and financial constraints. All patients perceived the intervention to be useful in reminding and motivating them to take medication. Median adherence (IQR) in the daily SMS, weekly SMS, and control arms was 96.1% (84.8, 98.0), 92.5% (80.6, 96.3), and 92.2% (56.3, 97.8), respectively; however, differences between the intervention and control arms were not statistically significant. Real-time monitoring linked to SMS was feasible and acceptable and may have improved TB medication adherence. Larger studies are needed to further assess impact on adherence and clinical outcomes. Trial registration. ClinicalTrials.gov registration number: NCT03800888. https://ichgcp.net/clinical-trials-registry/NCT03800888.

Digital Health Interventions to Enhance Tuberculosis Treatment Adherence: Scoping Review

Background

Digital health technologies are widely used for disease management, with their computing platforms, software, and sensors being used for health care. These technologies are developed to manage chronic diseases and infectious bacterial diseases, including tuberculosis (TB).

Objective

This study aims to comprehensively review the literature on the use of digital health interventions (DHIs) for enhancing TB treatment adherence and identify major strategies for their adoption.

Methods

We conducted a literature search in the PubMed, Cochrane Library, Ovid Embase, and Scopus databases for relevant studies published between January 2012 and March 2022. Studies that focused on web-based or mobile phone-based interventions, medication adherence, digital health, randomized controlled trials, digital interventions, or mobile health and ubiquitous health technology for TB treatment and related health outcomes were included.

Results

We identified 27 relevant studies and classified them according to the intervention method, a significant difference in treatment success, and health outcomes. The following interventions were emphasized: SMS text messaging interventions (8/27, 30%), medicine reminders (6/27, 22%), and web-based direct observation therapy (9/27, 33%). Digital health technology significantly promoted disease management among individuals and health care professionals. However, only a few studies addressed 2-way communication therapies, such as interactive SMS text messaging and feedback systems.

Conclusions

This scoping review classified studies on DHIs for patients with TB and demonstrated their potential for the self-management of TB. DHIs are still being developed, and evidence on the impact of digital technologies on enhancing TB treatment adherence remains limited. However, it is necessary to encourage patients' participation in TB treatment and self-management through bidirectional communication. We emphasize the importance of developing a communication system.

Multidisciplinary tuberculosis care: leveraging the role of hospital pharmacists

INTRODUCTION

Optimal pharmacological treatment of tuberculosis (TB) requires a multidisciplinary team, yet the hospital pharmacist's role is unclear. We aimed to analyse hospital pharmacist-provided clinical pharmacy services (CPS) implementation in TB care.

METHOD

A nationwide survey-based online cross-sectional study was conducted on hospital pharmacists in Indonesia from 1 November 2022 to 22 November 2022. Outcomes were the extent of pharmacists' involvement in multidisciplinary TB care, TB-related CPS provided and views on TB-related CPS. The probability of pharmacists' involvement in multidisciplinary TB teams was assessed using logistic regression.

RESULTS

In total, 439 pharmacists (mean age 31.2±6.22 years, 78% female) completed the survey. Thirty-six per cent were part of multidisciplinary TB care, and 23% had TB-related tasks. Adherence monitoring (90%) and drug use evaluation (86%) were the most conducted TB-related CPS. Pharmacists' views on TB-related CPS implementation were generally positive, except for financial incentives. Work experience (OR 1.99, 95% CI 1.09 to 3.61), ever received TB-related training (OR 3.51, 95% CI 2.03 to 6.14) and specific assignments to provide TB-related CPS (OR 8.42, 95% CI 4.99 to 14.59) significantly increased pharmacist involvement in multidisciplinary TB care.

CONCLUSION

Around one-third of hospital pharmacists are part of multidisciplinary TB care, with medication adherence and drug use monitoring as primary tasks. Pharmacists' experience, training, assignment to provide TB-related CPS and financial incentives are key elements for further implementation in multidisciplinary TB care. Pharmacists should proactively support current TB care and conduct operational research, sharing data with healthcare peers and fostering a collaborative multidisciplinary TB care team.

Knowledge, perception, and willingness to provide telepharmacy services among pharmacy students: a multicenter cross-sectional study in Indonesia

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic accelerated the provision of telepharmacy services. However, little is known about the knowledge, perception, and willingness of pharmacy students as future key players in telepharmacy adoption to provide such a service, particularly in a setting without well-established telepharmacy services before the COVID-19 pandemic.

OBJECTIVE

With this survey we aimed to assess the level of knowledge, perception, and willingness to provide telepharmacy services and to identify associated factors among pharmacy students in Indonesia.

METHODS

We applied a multicenter cross-sectional study design with convenience sampling technique among pharmacy students in three public universities in Bandung City, Surabaya City, and Special Region of Yogyakarta, Indonesia. The knowledge, perception, and willingness to provide telepharmacy services were assessed using an online questionnaire. Ordinal regression analysis was performed to determine factors associated with a high knowledge level, whereas binary logistic regression analyses were performed to determine factors associated with a positive perception of telepharmacy services. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported.

RESULTS

Among 313 respondents, 83.4% were female, and the mean age was 20 years. Although only 13.2% showed a high knowledge level, 66.5% showed a positive perception of telepharmacy services and 97.4% were willing to provide telepharmacy services in the future. An increase in age (OR 1.33; 95% CI 1.14-1.54) and being advance in smartphone usage (OR 5.21; 95% CI 2.03-13.42) are associated with an increased likelihood of having a high knowledge level about telepharmacy services. Male students had a lower likelihood of having a positive perception of telepharmacy services than females (OR 0.46; 95% CI 0.24-0.85).

CONCLUSION

Despite limited knowledge of telepharmacy, the majority of pharmacy students reported a positive perception and willingness to provide telepharmacy services in their future careers. Therefore, telepharmacy practice models must be included as a subject course in the curriculum, better preparing future pharmacists to perform their roles effectively. Furthermore, student-specific factors such as age and expertise in smartphone usage that associated with knowledge and gender that associated with perception should be considered to facilitate telepharmacy adoption in Indonesia.

Building bridges: multidisciplinary teams in tuberculosis prevention and care

People with or affected by tuberculosis (TB) experience complex social and cultural constraints that may affect treatment outcomes by impeding access to proper care or by hindering treatment adherence. Low levels of health literacy which leads to inadequate disease information; stigma, discrimination and other forms of prejudice that may result in marginalisation and ostracisation; and socioeconomic vulnerabilities that hamper one's capacity to access essential goods or increase the risk of exposure to the disease are some of the barriers highlighted. These complex hurdles are also disproportionately felt by people with or affected by TB due to gender-related inequalities that need to be properly addressed. Additionally, TB prevention and care should encompass interventions aimed at improving and promoting mental health, given that mental unhealth may further thwart treatment adherence and success. A multifaceted and multidisciplinary approach to TB is required to answer these complex barriers.

Practical Models of Pharmaceutical Care for Improving Tuberculosis Patient Detection and Treatment Outcomes: A Systematic Scoping Review

Decreasing global tuberculosis (TB) notifications indicate problems related to TB patient detection and treatment outcomes. Pharmaceutical care (PC) has potential roles in managing these issues. However, PC practices have not yet become widespread in the real world. This systematic scoping review aimed to identify and analyze the current literature on practical models of pharmaceutical care for improving tuberculosis patient detection and treatment outcomes. We then discussed the present challenges and future considerations for the successful implementation of PC services in TB. A systematic scoping review was performed to identify the practice models of PC in TB. Systematic searches and screening were used to identify relevant articles in the PubMed and Cochrane databases. We then discussed the challenges and recommendations for successful implementation using a framework to improve professional healthcare practice. Our analysis included 14 of 201 eligible articles. We identified that the focuses in the PC of TB are on increasing patient detection (four articles) and improving TB treatment outcomes (ten articles). Practices cover services in the community and hospital settings, such as screening and referring people with presumptive TB, tuberculin test services, collaborative practices for treatment completion, directly observed treatment, the solution of drug-related problems, reporting and managing adverse drug reactions, and medication adherence programs. Although PC services positively increase TB patient detection and treatment outcomes, hidden challenges in the actual practice are analyzed. Several factors should be comprehensively considered in successful implementation, such as guidelines, individual pharmacy personnel, patient, professional interaction, organizational capacity, regulation, incentive, and resource factors. Hence, a collaborative PC program that involves all related stakeholders should be considered to create successful and sustainable PC services in TB.

Digital adherence technologies to improve tuberculosis treatment outcomes in China: a cluster-randomised superiority trial

BACKGROUND

Drug-sensitive tuberculosis treatment requires 6 months of therapy, so adherence problems are common. Digital adherence technologies might improve tuberculosis treatment outcomes. We aimed to evaluate the effect of a daily reminder medication monitor, monthly review of adherence data by the health-care provider, and differentiated care for patients with adherence issues, on tuberculosis treatment adherence and outcomes.

METHODS

We did a cluster-randomised superiority trial across four prefectures in China. 24 counties or districts (clusters) were randomly assigned (1:1) to intervention or control groups. We enrolled patients aged 18 years or older with GeneXpert-positive, rifampicin-sensitive pulmonary tuberculosis, who were receiving daily fixed-dose combination treatment. Patients in the intervention group received a medication monitor for daily drug-dosing reminders, monthly review of adherence data by health-care provider, and management of poor adherence; and patients in the control group received routine care (silent-mode monitor-measured adherence). Only the independent endpoints review committee who assessed endpoint data for some participants were masked to study group assignment. Patients were followed up (with sputum solid culture) at 12 and 18 months. The primary outcome was a composite of death, loss to follow-up, treatment failure, switch to multidrug-resistant tuberculosis treatment, or tuberculosis recurrence by 18 months from treatment start, analysed in the intention-to-treat population. Analysis accounted for study design with multiple imputation for the primary outcome. This trial is now complete and is registered with ISRCTN, 35812455.

FINDINGS

Between Jan 26, 2017, and April 3, 2019, 15 257 patients were assessed for eligibility and 3074 were enrolled, 2686 (87%) of whom were included in the intention-to-treat population. 1909 (71%) of 2686 patients were male, 777 (29%) were female, and the median age was 44 years (IQR 29-58). By 18 months from treatment start, using multiple imputation for missing outcomes, 239 (16% [geometric mean of cluster-level proportion]) of 1388 patients in the control group and 224 (16%) of 1298 in the intervention group had a primary composite outcome event (289 [62%] of 463 events were loss to follow-up during treatment and 42 [9%] were tuberculosis recurrence). The intervention had no effect on risk of the primary composite outcome (adjusted risk ratio 1·01, 95% CI 0·73-1·40).

INTERPRETATION

Our digital medication monitor intervention had no effect on unfavourable outcomes, which included loss to follow-up during treatment, tuberculosis recurrence, death, and treatment failure. There was a failure to change patient management following identification of treatment non-adherence at monthly reviews. A better understanding of adherence patterns and how they relate to poor outcomes, coupled with a more timely review of adherence data and improved implementation of differentiated care, may be required.

FUNDING

Bill & Melinda Gates Foundation.

Digital Adherence Technologies and Mobile Money Incentives for Management of Tuberculosis Medication Among People Living With Tuberculosis: Mixed Methods Formative Study

BACKGROUND

Although there is an increasing use of digital adherence technologies (DATs), such as real-time monitors and SMS reminders in tuberculosis medication adherence, suboptimal patient engagement with various DATs has been reported. Additionally, financial constraints can limit DAT's utility. The perceived usefulness and the design mechanisms of DATs linked to mobile money financial incentives for tuberculosis medication management remain unclear.

OBJECTIVE

The aim of this study is to describe the perceived usefulness and design mechanisms for a DAT intervention called My Mobile Wallet, which is composed of real-time adherence monitors, SMS reminders, and mobile money incentives to support tuberculosis medication adherence in a low-income setting.

METHODS

This study used mixed methods approaches among persons with tuberculosis recruited from the Tuberculosis Clinic in the Mbarara Regional Referral Hospital. We purposively sampled 21 persons with tuberculosis aged 18 years and older, who owned cell phones and were able to use SMS text messaging interventions. We also enrolled 9 participants who used DATs in our previous study. We used focus group discussions with the 30 participants to solicit perceptions about the initial version of the My Mobile Wallet intervention, and then iteratively refined subsequent versions of the intervention following a user-centered design approach until the beta version of the intervention that suited their needs was developed. Surveys eliciting information about participants' cell phone use and perceptions of the intervention were also administered. Content analysis was used to inductively analyze qualitative data to derive categories describing the perceived usefulness of the intervention, concerns, and design mechanisms. Stata (version 13; StataCorp) was used to analyze survey data.

RESULTS

Participants expressed the perceived usefulness of the My Mobile Wallet intervention in terms of being reminded to take medication, supported with transport to the clinic, and money to meet other tuberculosis medication-related costs, all of which were perceived to imply care, which could create a sense of connectedness to health care workers. This could consequently cause participants to develop a self-perceived need to prove their commitment to adherence to health care workers who care for them, thereby motivating medication adherence. For fear of unintended tuberculosis status disclosure, 20 (67%) participants suggested using SMS language that is confidential-not easily related to tuberculosis. To reduce the possibilities of using the money for other competing demands, 25 (83%) participants preferred sending the money 1-2 days before the appointment to limit the time lag between receiving the money and visiting the clinic.

CONCLUSIONS

DATs complemented with mobile money financial incentives could potentially provide acceptable approaches to remind, support, and motivate patients to adhere to taking their tuberculosis medication.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05656287; https://clinicaltrials.gov/ct2/show/NCT05656287.

Effectiveness of digital adherence technologies in improving tuberculosis treatment outcomes in four countries: a pragmatic cluster randomised trial protocol

INTRODUCTION

Successful treatment of tuberculosis depends to a large extent on good adherence to treatment regimens, which relies on directly observed treatment (DOT). This in turn requires frequent visits to health facilities. High costs to patients, stigma and burden to the health system challenged the DOT approach. Digital adherence technologies (DATs) have emerged as possibly more feasible alternatives to DOT but there is conflicting evidence on their effectiveness and feasibility. Our primary objective is to evaluate whether the implementation of DATs with daily monitoring and a differentiated response to patient adherence would reduce poor treatment outcomes compared with the standard of care (SOC). Our secondary objectives include: to evaluate the proportion of patients lost to follow-up; to compare effectiveness by DAT type; to evaluate the feasibility and acceptability of DATs; to describe factors affecting the longitudinal engagement of patients with the intervention and to use a simple model to estimate the epidemiological impact and cost-effectiveness of the intervention from a health system perspective.

METHODS AND ANALYSIS

This is a pragmatic two-arm cluster-randomised trial in the Philippines, South Africa, Tanzania and Ukraine, with health facilities as the unit of randomisation. Facilities will first be randomised to either the DAT or SOC arm, and then the DAT arm will be further randomised into medication sleeve/labels or smart pill box in a 1:1:2 ratio for the smart pill box, medication sleeve/label or the SOC respectively. We will use data from the digital adherence platform and routine health facility records for analysis. In the main analysis, we will employ an intention-to-treat approach to evaluate treatment outcomes.

ETHICS AND DISSEMINATION

The study has been approved by the WHO Research Ethics Review Committee (0003296), and by country-specific committees. The results will be shared at national and international meetings and will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN17706019.

Half a Century of Fragmented Research on Deviations from Advised Therapies: Is This a Good Time to Call for Multidisciplinary Medication Adherence Research Centres of Excellence?

Medication adherence is a key precondition of the effectiveness of evidence-based therapies. However, in real-life settings, non-adherence to medication is still very common. This leads to profound health and economic consequences at both individual and public health levels. The problem of non-adherence has been extensively studied in the last 50 years. Unfortunately, with more than 130,000 scientific papers published on that subject so far, we are still far from finding an ultimate solution. This is, at least partly, due to fragmented and poor-quality research that has been conducted in this field sometimes. To overcome this deadlock, there is a need to stimulate the adoption of best practices in medication adherence-related research in a systematic way. Therefore, herein we propose the establishment of dedicated medication adherence research Centres of Excellence (CoEs). These Centres could not only conduct research but could also create a profound societal impact, directly serving the needs of patients, healthcare providers, systems and economies. Additionally, they could play a role as local advocates for good practices and education. In this paper, we propose some practical steps that might be taken in order to establish such CoEs. We describe two success stories, i.e., Dutch and Polish Medication Adherence Research CoEs. The COST Action “European Network to Advance Best practices & technoLogy on medication adherencE” (ENABLE) aims to develop a detailed definition of the Medication Adherence Research CoE in the form of a list of minimal requirements regarding their objectives, structure and activities. We hope that it will help to create a critical mass and catalyse the setup of regional and national Medication Adherence Research CoEs in the near future. This, in turn, may not only increase the quality of the research but also raise the awareness of non-adherence and promote the adoption of the best medication adherence-enhancing interventions.

Effect of mobile health reminders on tuberculosis treatment outcomes in Shanghai, China: A prospective cohort study

Background

Poor adherence increases the risk of unfavorable outcomes for tuberculosis (TB) patients. Mobile health (mHealth) reminders become promising approaches to support TB patients' treatment. But their effects on TB treatment outcomes remain controversial. In this prospective cohort study, we evaluated the effect of the reminder application (app) and the smart pillbox on TB treatment outcomes compared with the standard care in Shanghai, China.

Methods

We recruited new pulmonary TB (PTB) patients diagnosed between April and November 2019 who were aged 18 or above, treated with the first-line regimen (2HREZ/4HR), and registered at Songjiang CDC (Shanghai). All eligible patients were invited to choose the standard care, the reminder app, or the smart pillbox to support their treatment. Cox proportional hazard model was fitted to assess the effect of mHealth reminders on treatment success.

Results

260 of 324 eligible patients enrolled with 88 using standard care, 82 the reminder app, and 90 the smart pillbox, followed for a total of 77,430 days. 175 (67.3%) participants were male. The median age was 32 (interquartile range [IQR] 25 to 50) years. A total of 44,785 doses were scheduled for 172 patients in the mHealth reminder groups during the study period. 44,604 (99.6%) doses were taken with 39,280 (87.7%) monitored by the mHealth reminders. A significant time-dependent downward linear trend was observed in the monthly proportion of dose intake (p < 0.001). 247 (95%) patients were successfully treated. The median treatment duration of successfully treated patients in the standard care group was 360 (IQR 283-369) days, significantly longer than those in the reminder app group (296, IQR 204-365, days) and the smart pillbox group (280, IQR 198-365, days) (both p < 0.01). Using the reminder app and the smart pillbox was associated with 1.58 times and 1.63 times increase in the possibility of treatment success compared with the standard care, respectively (both p < 0.01).

Conclusion

The reminder app and the smart pillbox interventions were acceptable and improved the treatment outcomes compared with the standard care under the programmatic setting in Shanghai, China. More high-level evidence is expected to confirm the effect of mHealth reminders on TB treatment outcomes.

Clinical and economic burden of drug-susceptible tuberculosis in Indonesia: national trends 2017-19

BACKGROUND

The global incidence of tuberculosis is decreasing, yet it remains high in Indonesia. The Indonesian National Tuberculosis Program facilitates mandatory notification, which enables early detection and treatment, minimises complications, prevents transmission, and decreases deaths. This study aimed to assess the characteristics, trends, and economic burden of notified drug-susceptible tuberculosis cases registered in this system from 2017 to 2019.

METHODS

We performed a multiyear cross-sectional study focusing on drug-susceptible tuberculosis notified cases, incidence, geographical tuberculosis case distribution, treatment outcomes, and costs in Indonesia using data from Sistem Informasi Tuberkulosis (2017-19). The settings were Indonesian health-care facilities that provide tuberculosis control programmes and services. Eligible patients were those who were diagnosed with drug-susceptible tuberculosis and notified to Sistem Informasi Tuberkulosis.

FINDINGS

Between 2017 and 2019, notified cases increased from 429 219 to 523 614 individuals, corresponding to an increase in incidence from 167 cases per 100 000 to 196 cases per 100 000. In 2019, more than 250 cases per 100 000 inhabitants were notified in Jakarta, North Sulawesi, Gorontalo, and Papua. Treatment success rate increased from 363 098 (84·60%) of 429 219 in 2017 to 452 966 (86·51%) of 523 614 in 2019, with a relatively stable mortality, changing from 3·15% to 3·05%. HIV status was increasingly confirmed, with unknown status decreasing from 66·21% to 43·68%. The costs of visits and monitoring and drug regimens were relatively stable, with total direct medical costs slightly increasing from US$39·40 to $40·40 per case.

INTERPRETATION

Progress was made on drug-susceptible tuberculosis management in Indonesia. However, further intensified efforts, including case-finding, optimising diagnosis, and cost-effective tuberculosis management are required if Indonesia is to achieve the 2025 WHO End Tuberculosis Strategy target incidence of fewer than 55 cases per 100 000 people. These data are an important starting point for understanding drug-susceptible tuberculosis dynamics in Indonesia and optimising its management.

FUNDING

Directorate General of Higher Education; Ministry of Education, Culture, Research, and Technology of the Republic of Indonesia.

Identification of preferred reminder systems and patient factors to promote adherence in the management of urinary incontinence

Objective

To investigate comfort level and preferences of automated reminder systems (mail, email, text message, phone call, patient-portal message, and/or smartphone application) to promote adherence to recommended therapies for patients seeking care for urinary incontinence (UI) at our urology clinic in Phoenix, Arizona.

Methods

Anonymous surveys were distributed in English to adult patients with UI from 4/2019-5/2019. Patient demographics, UI type, and access to and use of the Internet, smartphone and patient-portal were assessed. Using a Likert scale, patients indicated level of comfort with each reminder system and numerically ranked each system. Statistical analyses were performed to identify patient characteristics associated with reminder modality and determine significance in ranking of systems.

Results

Fifty-seven patients (67.3 ± 16.3 years) completed the survey with an 87% response rate. Text-message and phone call reminder modalities were ranked the highest compared to other modalities (p < 0.05). A Chi-squared test showed no correlation between preferred reminder system modality and type of incontinence, age, gender, race/ethnicity, or language spoken (p > 0.05). Internet usage and access significantly correlated with preference for smartphone application and patient-portal message reminder systems (p < 0.05).

Conclusion

Patients reported they were extremely comfortable with all communication modalities, except for smartphone applications in which patients were the least comfortable. The modalities most preferred by patients were phone call and text message and least preferred were patient portal and smart phone application. In conclusion, phone calls and text messages were the most preferred communication modality, with smart phone applications as the least comfortable.

Innovation

This study demonstrates the potential utility of specific reminder modalities for patients seeking help with treatment adherence.

Knowledge, attitude and practice of community pharmacy personnel in tuberculosis patient detection: a multicentre cross-sectional study in a high-burden tuberculosis setting

INTRODUCTION

Control of tuberculosis (TB) is hampered by suboptimal case detection and subsequent delays in treatment, which is worsened by the COVID-19 pandemic. The community pharmacy is reported as the place for first aid medication among patients with TB. We, therefore, analysed knowledge, attitude and practice (KAP) on TB patient detection (TBPD) of community pharmacy personnel, aiming to find innovative strategies to engage community pharmacies in TBPD.

METHODS

A multicentre cross-sectional study was performed in four areas of Indonesia's eastern, central and western parts. Pharmacists and pharmacy technicians who worked in community pharmacies were assessed for their characteristics and KAP related to TBPD. Descriptive analysis was used to assess participant characteristics and their KAP, while multivariable regression analyses were used to analyse factors associated with the KAP on TBPD.

RESULTS

A total of 1129 participants from 979 pharmacies, comprising pharmacists (56.6%) and pharmacy technicians (43.4%), were included. Most participants knew about TB. However, knowledge related to TB symptoms, populations at risk and medication for TB were still suboptimal. Most participants showed a positive attitude towards TBPD. They believed in their professional role (75.1%), capacity in TB screening (65.4%) and responsibility for TBPD (67.4%). Nevertheless, a lack of TBPD practice was identified in most participants. Several factors significantly associated with performing the TBPD practice (p<0.05), such as TB training experience (p<0.001), provision of a drug consultation service (p<0.001), male gender (p<0.05), a positive attitude towards TBPD (p<0.001), short working hours (p<0.001) and central city location of the pharmacy (p<0.05).

CONCLUSIONS

Most participants had good knowledge and attitude, which did not translate into actual TBPD practice. We identified that TB educational programmes are essential in improving the KAP. A comprehensive assessment is needed to develop effective strategies to engage the community pharmacy in TBPD activities.

Barriers to Optimal Tuberculosis Treatment Services at Community Health Centers: A Qualitative Study From a High Prevalent Tuberculosis Country

Background: Community health centers (CHCs) are a backbone healthcare facility for tuberculosis (TB) services. Identifying barriers amongst TB service providers at the CHC level is required to help them deliver successful TB treatment.

Aims: The current study aimed to analyze barriers to successful TB treatment from the perspective of TB service providers at the CHC level in a high prevalent TB country.

Methods: A qualitative study was conducted using in-depth interviews and focus group discussions in a province of Indonesia with a high TB prevalence. Two districts representing rural and urban areas were selected to obtain information from TB service providers (i.e., physicians and nurses) at the CHC level. In addition, key informant interviews with TB patients, hospital TB specialists, pharmacists, and activists were conducted. The trustworthiness and credibility of the information were established using information saturation, participant validation, and triangulation approaches. The interviews were also transcribed for the inductive analysis using Atlas.ti 8.4 software.

Results: We identified 210 meaning units from 48 participants and classified them into two main themes: organizational capacity and TB program activities. We identified the inadequacy of human resources, facility, and external coordination as the main barriers to organizational capacity. Furthermore, the barriers were identified regarding TB program activities, that is, inadequate TB case finding, diagnosis, drug supply chain and dispensing management, treatment and monitoring, case recording and reporting, and public-private collaboration.

Conclusion: Strengthening CHCs in the management of TB is critical to reaching the national and global goals of TB eradication by 2035. These findings can be considered to develop evaluation strategies to improve the successful TB treatment in high prevalent TB countries, especially Indonesia.