Acceptance of digital health services among older adults: Findings on perceived usefulness, self-efficacy, privacy concerns, ICT knowledge, and support seeking

Improved Perioperative Risk Education Through the Use of an Interactive Online Anaesthesia Education Tool (iPREDICT): A Prospective, Randomised Controlled Single-Centre Clinical Trial

Background/Objectives: Involving patients in the preoperative anaesthetic assessment (PAA) process can improve their understanding of risks and contribute to better postoperative recovery and outcomes. The iPREDICT study aims to investigate the feasibility of using an interactive consultation tool (ICT) to improve patient awareness of anaesthesia-related risks. Methods: This prospective, single-centre, randomised, placebo-controlled clinical study included patients scheduled for elective surgery under general or combined general and regional anaesthesia. Participants were randomly assigned to online anaesthesia risk education in the ICT group (intervention) or a control group that watched a video without anaesthetic risk content. Both groups received a face-to-face PAA and were assessed about anaesthetic risk knowledge after PAA and two days later. Results: A total of 373 participants were randomised, and 315 completed the assigned online module prior to their PAA. The proportion of male participants was higher (>60%). Most participants already had prior anaesthesia experience. After PAA, 243 patients completed the first risk recall #1 questionnaire, with the ICT group identifying significantly more correct risks than the control group (median 13.0 vs. 11.0, p < 0.05). In risk recall #2, conducted two days after the PAA, knowledge retention remained stable in the control group, while the experimental group showed further improvement (median 14.0 vs. 13.0, p < 0.05). Conclusions: Using the ICT significantly improved patients' knowledge of anaesthesia-related risks. These results suggest that interactive patient education tools are a feasible and effective way to improve patients' understanding of perioperative anaesthesia risks, potentially contributing to better outcomes, which needs to be addressed in future projects.

Social Media and eHealth Literacy Among Older Adults: Systematic Literature Review

BACKGROUND

The advent of social media has significantly transformed health communication and the health-related actions of older adults, offering both obstacles and prospects for this generation to embrace eHealth developments.

OBJECTIVE

We aimed to investigate the correlation between social media and eHealth literacy in older individuals and answer four research questions: (1) What are the specific social media behaviors (including general use behaviors and health behaviors) of older adults on social media? (2) How do these behaviors impact their eHealth literacy? (3) How does eHealth literacy influence older adults' social media behaviors? and (4) What factors influence older adults' use of social media for health-related purposes?

METHODS

Using predetermined keywords and inclusion criteria, we searched Scopus, Web of Science, and PubMed databases for English-language journal articles published from 2000 to 2024, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) principles. The initial search identified 1591 publications, and after removing duplicates, 48.21% (767/1591) of publications remained. Ultimately, 1% (16/1591) of studies met the inclusion criteria. A research question-driven manual qualitative thematic analysis was conducted, guided by the categorization of social media use behaviors, the definition of eHealth literacy, and the social-ecological model to provide direction for coding and thematic analysis. In addition, attention was given to identifying unanticipated behaviors or phenomena during the coding process, and these were subsequently incorporated into the analytical framework.

RESULTS

The results indicated that older adults' general social media use behaviors are primarily characterized by social media preferences, with 2 subthemes identified. Their social media health behaviors revealed 5 main themes and 14 subthemes. Among the primary themes, health information behavior appeared most frequently (12/16, 75%), followed by self-management (8/16, 50%). Other themes included health decision-making (4/16, 25%), telemedicine (3/16, 19%), and health interventions (2/16, 13%). Cross-thematic analysis confirmed that older adults' social media use behaviors and their eHealth literacy had a reciprocal relationship. Finally, the study revealed that the use of social media to improve eHealth literacy among older adults was influenced by individual, interpersonal, institutional or organizational, and social factors.

CONCLUSIONS

The reciprocal relationship between older adults' social media use and eHealth literacy highlights the importance of establishing a long-term positive mechanism that mutually reinforces social media health practices and eHealth literacy. Based on the findings, this review proposes key directions for efforts to achieve this goal: (1) leveraging postpandemic momentum to enhance eHealth literacy among older adults through social media, (2) reconsidering the dimensions of eHealth literacy among older adults in the context of Web 2.0, (3) actively developing age-friendly integrated social media health service platforms, (4) optimizing social media for engaging and reliable health information for older adults, and (5) integrating social support systems to foster lifelong eHealth learning for older adults.

The Role of Environmental Factors in Technology-Assisted Physical Activity Intervention Studies Among Older Adults: Scoping Review

BACKGROUND

The rapidly emerging integration of both technological applications and environmental factors in physical activity (PA) interventions among older adults highlights the need for an overarching investigation.

OBJECTIVE

This scoping review compiled the current literature and aimed to provide an overview of the role of physical, social, socioeconomic, and systemic environmental factors in technology-assisted PA interventions for older adults.

METHODS

We systematically searched 6 common databases up to September 16, 2024, for original longitudinal studies (with at least one preintervention measurement and one postintervention measurement) that reported on the role of environmental factors in technology-assisted PA interventions for independently living, community-dwelling older adults. In a stepwise process, data on study characteristics (step 1), environmental factors and their role in the included studies (step 2), and intervention outcomes and effects by type of environmental factor (step 3) were summarized.

RESULTS

A total of 8020 articles were screened, and 25 (0.31%) were included. Most studies were conducted in Europe (11/25, 44%), followed by North America (5/25, 20%), Asia (5/25, 20%), and Oceania (4/25, 16%). Social environmental factors were most often considered (19/25, 76%), followed by factors from the physical (8/25, 32%), socioeconomic (1/25, 4%), and systemic environment (1/25, 4%). Environmental factors were used as the outcome (8/25, 32%), setting variable (7/25, 28%), moderator or facilitator (8/25, 32%), and intervention component (3/25, 12%). In most studies (19/25, 76%), the intervention had a beneficial effect on the outcome of interest, and the included environmental factor played a supportive role in achieving this effect. In some studies, no effect (3/25, 12%), mixed effects (2/25, 8%), or adverse effects (1/25, 4%) of the interventions were reported.

CONCLUSIONS

This is the first comprehensive description of how environmental factors interact with technology-assisted interventions to increase or optimize PA in older adults. It was found that the investigation of environmental factors in this field is at an early stage. Environmental factors were found to play a supportive role in achieving beneficial effects of technology-assisted PA interventions, but the findings were based on a heterogeneous empirical platform. Still, certain aspects such as the application of virtual reality environments and social (or peer) comparison have shown significant potential that remains to be leveraged. A better understanding of intervention results and support in tailoring intervention programs can be provided through the inclusion of environmental aspects in technology-assisted PA interventions for older adults.

Study on the "digital divide" in the continuous utilization of Internet medical services for older adults: Combination with PLS-SEM and fsQCA analysis approach

BACKGROUND

With the rapid digitalization of healthcare and an aging population, understanding the factors influencing older adults' sustained adoption of Internet medical services is critical. However, existing research often oversimplifies these factors by relying on linear models. This study integrates Partial Least Squares Structural Equation Modeling (PLS-SEM) and fuzzy-set Qualitative Comparative Analysis (fsQCA) to explore the complex pathways driving continued use.

METHODS

A survey of 1,920 older adults (60-75 years) in China assessed satisfaction, e-health literacy, self-efficacy, social support, social influence, social participation, and willingness to use Internet medical services. PLS-SEM examined the relationships between variables, while fsQCA identified multiple configurations leading to sustained use.

RESULTS

PLS-SEM identified satisfaction as the strongest predictor of sustained use (β = 0.281, p < 0.001), acting as both a direct determinant and a mediator for e-health literacy and social participation. Social influence (β = 0.189, p < 0.001) and social support (β = 0.172, p < 0.001) also contributed significantly. FsQCA revealed six distinct configurations, with satisfaction and e-health literacy as core conditions across most pathways.

CONCLUSIONS

By integrating linear and configurational approaches, this study provides a nuanced understanding of older adults' digital healthcare behaviors. Enhancing satisfaction, digital literacy, and social engagement is key to fostering sustained adoption. Tailored interventions based on distinct configurations can maximize the effectiveness of digital health programs.

IMPLICATIONS

This research bridges gaps in understanding complex behaviors and provides actionable insights for policymakers and healthcare providers, highlighting the critical role of digital literacy and social support.

"Life has always been physical physical, now visual": an explorative study on the use of digital health technologies to promote physiotherapy home treatment programs among older people

BACKGROUND

There has been a recent rise in the use of technology for health promotional practices, which have begun to gain popularity among physiotherapists but not much research has been conducted to explore its many opportunities and challenges among older adults in developing countries.

OBJECTIVES

To explore Nigerian-based Physiotherapists' perspectives on how digital health technologies (DHT) can be utilized to promote physiotherapy home treatment programs among Nigerian older people.

METHODS

This is a one-on-one semi-structured interview of 12 geriatric physiotherapists (7 Male, 5 female) virtually in the Teams Meeting platform. Data generated were analyzed thematically using the latest version of NVivo software.

RESULTS

Three overarching themes were conceptualized including the usage of DHT in Nigeria, challenges to DHT application, and strategies to improve DHT usage. These described a low awareness and usage of DHT despite its recognized need and advantages for promoting home program. The forms of DHT commonly being used are mostly mobile-based through calls or texts, which could be due to barriers to the use of DHT including older people's declining cognition, poverty, and low interest in technology. Some external problems included the physiotherapists' attachment to hands-on practice and low commitment from the informal caregivers.

CONCLUSIONS

These findings suggested ways to utilize the DHT in promoting physiotherapy home treatment programs among older people by encouraging technological innovations and raising awareness among physiotherapists, while the physiotherapists need to patiently educate both the older people and involve their informal caregivers.

Digital health technologies and self-efficacy in Parkinson's: a scoping review

OBJECTIVE

Prior research has identified that people with Parkinson's reporting lower levels of self-efficacy exhibit worsening motor and non-motor symptomology, reduced quality of life, and self-management. Our key objective was to conduct a scoping review examining the impact of digital health technologies on self-efficacy in people with Parkinson's.

DESIGN

A scoping review using Arksey and O'Malley's (2005) framework was undertaken.

DATA SOURCES

MEDLINE, Embase, PsychINFO, CINAHL, Web of Science, IEEE Xplore, and Google Scholar principally for grey literature were searched from 1 January 2008 to the 24th of July 2024.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Primary studies which incorporated digital health technologies, measured self-efficacy and had a sample population of people with Parkinson's were searched.

DATA EXTRACTION AND SYNTHESIS

Following identification of potentially eligible records, two independent reviewers undertook title and abstract screening, followed by full-text screening. Data was extracted using our earlier published data extraction sheet which incorporated the Practical Reviews in Self-Management Support (PRISMS) taxonomy, and the template for intervention description and replication (TIDieR) checklist. Data was extracted from a Microsoft Excel spreadsheet and synthesised by describing themes, demographic data and numerical data.

RESULTS

From 33 165 unique records following screening and independent review by two reviewers, 11 eligible records were found. Of these five elevated self-efficacy to a statistically significant level, five did not and one lowered self-efficacy. Of the studies which raised self-efficacy to a statistically significant level, all adopted a multimodal approach with a variety of devices. Thematically, these devices were focused on physical activity, falls/falls prevention, or both. The level of heterogeneity precluded comparisons between studies.

CONCLUSIONS

This scoping review identified significant knowledge and evidence gaps in the literature, and the limited number of eligible studies make these findings not generalisable. Future self-management research might benefit from also considering self-efficacy.

Patient perceptions of digital and therapist-led CBT for insomnia: A qualitative study

OBJECTIVES

Technology has the potential to increase access to evidence-based insomnia treatment. Patient preferences/perceptions of automated digital cognitive behavior therapy for insomnia (CBTI) and telehealth-delivered CBTI remain largely unexplored among middle-aged and older adults. Using a qualitative approach, the current study describes patients' reasons for participating in the clinical trial, preferences for digital CBTI (dCBTI) versus therapist-led CBTI, patient attitudes toward dCBTI, and patient attitudes toward telehealth-delivered therapist-led CBTI.

METHOD

Middle-aged and older adults (N = 80) completed a semi-structured interview before CBTI exposure. Qualitative responses were coded, and themes were inductively extracted.

RESULTS

Most (62.5%) of the participants expressed a preference for therapist-led CBTI to dCBTI. Convenience was the most commonly reported advantage of dCBTI (n = 55) and telehealth-delivered CBTI (n = 65). Decreasing transit time and pandemic-related health concerns were identified as advantages to dCBTI and telehealth-delivered CBTI. Lack of human connection and limited personalization were perceived as disadvantages of dCBTI. Only three participants reported technological barriers to dCBTI and telehealth-delivered CBTI.

CONCLUSION

Findings suggest that, despite an overall preference for therapist-led treatment, most middle-aged and older adults are open to dCBTI. As both dCBTI and telehealth-delivered CBTI are perceived as convenient, these modalities offer the potential to increase access to insomnia care.

Can cultural capital, cognitive ability, and economic capacity help rural older adults bridge the digital divide? Evidence from an empirical study

BACKGROUND

The digital divide is the difference between individuals who use the Internet and those who do not. Under the triple social environment of urban-rural dichotomy, population aging, and the digital era in China, the existence of digital divide among rural older adults has seriously affected their access to health information through the Internet, so it is urgent to bridge the digital divide problem they face.

METHODS

Based on Maslow's Hierarchy of Needs Theory and Stress Coping Theory, the impact of cultural capital on the digital divide among rural older adults was systematically analyzed using hierarchical regression and Chained Mediation Effect Tests using data from the Chinese Family Panel Studies (CFPS).

RESULTS

Cultural capital has a significant positive effect on the digital divide among rural older adults (β = 0.178, p < 0.01). Cognitive ability and economic capacity both play independent intermediary effects between cultural capital and digital divide among rural older adults, and the intermediary chain formed by the two plays a chain intermediary effect. The increase in the cultural capital of rural older adults has led to an increase in their cognitive ability and economic capacity, which ultimately has a favorable effect on the bridging of the digital divide. Heterogeneity results suggest that cultural capital is more effective in bridging the digital divide among male rural older adults aged 60-69.

CONCLUSION

Cultural capital is able to bridge the digital divide faced by rural older adults and is age and gender heterogeneous. At the same time, improved cognitive ability and economic capacity can also help rural older adults bridge the digital divide. Therefore, it is proposed that we increase the construction of public cultural service infrastructure in rural areas, liaise with community neighborhood committees and village committees to do a good job of publicity, improve training measures for key groups, and maintain the enthusiasm of rural older adults for learning, so as to provide references for the rural older adults in China and developing countries in general to bridge the digital divide.

Internet Use as a Moderator of the Relationship Between Personal Resources and Stress in Older Adults: Cross-Sectional Study

BACKGROUND

Internet use has dramatically increased worldwide, with over two-thirds of the world's population using it, including the older adult population. Technical resources such as internet use have been shown to influence psychological processes such as stress positively. Following the Conservation of Resources theory by Hobfoll, stress experience largely depends on individuals' personal resources and the changes in these resources. While personal resource loss has been shown to lead to stress, we know little regarding the role that technical resources may play on the relationship between personal resources and stress.

OBJECTIVE

This study aims to investigate the moderating effect of technical resources (internet use) on the relationship between personal resources and stress in younger and older adults.

METHODS

A total of 275 younger adults (aged 18 to 30 years) and 224 older adults (aged ≥65 years) indicated their levels of stress; change in personal resources (ie, cognitive, social, and self-efficacy resource loss and gain); and internet use. Variance analyses, multiple regression, and moderation analyses were performed to investigate the correlates of stress.

RESULTS

Results showed that older adults, despite experiencing higher levels of resource loss (questionnaire scores: 1.82 vs 1.54; P<.001) and less resource gain (questionnaire scores: 1.82 vs 2.31; P<.001), were less stressed than younger adults (questionnaire scores: 1.99 vs 2.47; P<.001). We observed that the relationship among resource loss, resource gain, and stress in older adults was moderated by their level of internet use (β=.09; P=.05). Specifically, older adults who used the internet more frequently were less stressed when they experienced high levels of both loss and gain compared to their counterparts who used internet the less in the same conditions. Furthermore, older adults with low resource gain and high resource loss expressed less stress when they used the internet more often compared to those with low internet use.

CONCLUSIONS

These findings highlight the importance of internet use in mitigating stress among older adults experiencing resource loss and gain, emphasizing the potential of digital interventions to promote mental health in this population.

Digital home care interventions and quality of primary care for older adults: a scoping review

BACKGROUND

Population aging is forcing the transformation of health care. Long-term care in the home is complex and involves complex communication with primary care services. In this scenario, the expansion of digital health has the potential to improve access to home-based primary care; however, the use of technologies can increase inequalities in access to health for an important part of the population. The aim of this study was to identify and map the uses and types of digital health interventions and their impacts on the quality of home-based primary care for older adults.

METHODS

This is a broad and systematized scoping review with rigorous synthesis of knowledge directed by the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The quantitative data were analyzed through descriptive statistics, and the qualitative data were analyzed through basic qualitative content analysis, considering the organizational, relational, interpersonal and technical dimensions of care. The preliminary results were subjected to consultation with stakeholders to identify strengths and limitations, as well as potential forms of socialization.

RESULTS

The mapping showed the distribution of publications in 18 countries and in the Sub-Saharan Africa region. Older adults have benefited from the use of different digital health strategies; however, this review also addresses limitations and challenges, such as the need for digital literacy and technological infrastructure. In addition to the impacts of technologies on the quality of health care.

CONCLUSIONS

The review gathered priority themes for the equitable implementation of digital health, such as access to home caregivers and digital tools, importance of digital literacy and involvement of patients and their caregivers in health decisions and design of technologies, which must be prioritized to overcome limitations and challenges, focusing on improving quality of life, shorter hospitalization time and autonomy of older adults.

Factors influencing older adults' participation in telehealth interventions for primary prevention and health promotion: A rapid review

OBJECTIVE

To identify facilitators and barriers to older adults' participation in telehealth interventions for primary prevention and health promotion.

METHODS

Relevant articles were searched using keywords in Embase and MEDLINE. Study characteristics, type of telehealth interventions and technology involved, as well as facilitators and barriers to their use, were extracted from selected articles. The Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) model was used to organise data.

RESULTS

A total of 24 articles (pertaining to 20 studies) were included. Nine facilitators and 11 barriers influencing the participation in telehealth interventions for primary prevention and health promotion among older adults were identified. The most recurrent facilitators were related to the individual's performance expectancy and effort expectancy, as well as the presence of a social dimension associated with the intervention (i.e. having a good relationship with the other participants in the program). The two most prevalent barriers were also related to effort expectancy and performance expectancy, followed by barriers related to the inherent characteristics of the technology and older adults' health condition. Experience, age and gender were also found to moderate technology use and acceptance.

CONCLUSIONS

This rapid review highlights the importance of adopting a holistic perspective when designing telehealth interventions aimed at preventive and health promotion purposes among older adults.

Mapping the landscape: A bibliometric analysis of information and communication technology adoption by older adults with cognitive frailty or impairment

The adoption of information and communication technology (ICT) by older adults with cognitive frailty and impairment is beneficial to support aging in place and promote healthy aging. However, data are scarce regarding the use of ICT by this demographic in comparison with other age groups. This bibliometric analysis was aimed at systematically mapping the literature on ICT-related research on older adults with cognitive frailty and cognitive impairment to provide insights into research trends, patterns and knowledge gaps. Data were extracted from the Web of Science database, which identified 324 publications between 1980 and 2023. Performance analysis and science mapping were carried out using Microsoft® Excel, VOSViewer and Harzing's Publish or Perish. The analysis showed an upsurge in the research output trend over time. Notable journals, authors, citations, nations and research areas have been documented. Four key clusters were identified, including: (i) caregiver concern, support and involvement; (ii) technology as a tool for cognitive training and cognitive rehabilitation; (iii) cognitive improvement; and (iv) the use of technology for prevention and self-management. The findings derived from this analysis provide an appropriate reference for future researchers to bridge the gap in ICT-related studies among this population, and distinguish the relevant articles that are required for further investigation. These include the need for further long-term research, the incorporation of ICT-based approaches to counter cognitive frailty and the importance of multidomain telehealth interventions. Geriatr Gerontol Int 2024; 24: 251-262.

Privacy concerns among the users of a national patient portal: A cross-sectional population survey study

INTRODUCTION

Seeking and receiving care requires disclosure of personal information which is recorded as health data in electronic health records. Thereafter, restricting the flow of information is dependent on data protection, information security, ethical conduct, and law. Privacy concerns may arise as patients' options concerning privacy have been balanced to cater both the privacy of patients and the needs of healthcare, as well as secondary use of data.

METHODS

This study examined privacy concerns among the users of a national patient portal in a representative sample of Finnish adults aged 20 to 99 years old (n = 3,731). We used logistic regression analysis with population weights to seek answers to which factors are associated with privacy concerns. The cross-sectional survey data was collected in 2020.

RESULTS

Every third patient portal user had privacy concerns. Those who were 50 to 59 years old (p = 0.030) had privacy concerns more often than 20 to 49-year-olds. Those who had financial difficulties (p = 0.003) also had privacy concerns more often while those, who had good digital skills (p=<0.026), did not need guidance on telehealth service use (p=<0.001) and found telehealth service use to be beneficial (p = 0.008), had privacy concerns less often.

CONCLUSION

The usefulness of telehealth seems to play an important role in privacy concerns. Another important factor is the skills required to use telehealth services. We encourage providing guidance to those who lack the necessary skills for telehealth service use. We also encourage putting effort not only into data protection and information security measures of telehealth services, but also into providing transparent and comprehensible privacy information for the service users as privacy concerns are common.

Ambulatory anesthesia: restructuring for success

PURPOSE OF REVIEW

We review current evidence about organizational structures, patient selection criteria, safety measures, economic considerations, quality management, and staffing challenges in ambulatory anesthesia. The focus is on the facilitators and barriers related to the peri-interventional period and the potential concepts and innovations for the future development of ambulatory anesthesia services.

RECENT FINDINGS

Recent findings shed light on organizational structures in ambulatory anesthesia, including hospital-based centers, freestanding ambulatory centers, and office-based practices. Patient selection for ambulatory anesthesia involves a two-step process, considering both surgical and anesthetic factors. Safety measures, such as standardized guidelines and scoring systems, aim to ensure patient well being during the perioperative course. Economic considerations pose challenges due to the complexities of managing operating room efficiency and the variations in reimbursement systems. Quality management in ambulatory anesthesia emphasizes the need for outcome studies and patient-centered quality indicators. Staffing requirements necessitate highly skilled professionals with both technical and nontechnical skills, and structured education and training are essential.

SUMMARY

Ambulatory anesthesia is gaining importance due to advancements in surgical techniques and peri-interventional care. The review highlights the need for addressing challenges related to organizational structures, patient selection, patient safety, economic considerations, quality management, and staffing in ambulatory anesthesia. Understanding and addressing these factors are crucial for promoting the further development and improvement of ambulatory anesthesia services.

Acceptability and feasibility of digital adherence technologies for drug-susceptible tuberculosis treatment supervision: A meta-analysis of implementation feedback

Digital adherence technologies (DATs) have emerged as an alternative to directly observed therapy (DOT) for supervisions of tuberculosis (TB) treatment. We conducted a meta-analysis of implementation feedback obtained from people with TB and health care workers (HCWs) involved in TB REACH Wave 6-funded DAT evaluation projects. Projects administered standardized post-implementation surveys based on the Capability, Opportunity, Motivation, Behavior (COM-B) model to people with TB and their health care workers. The surveys included questions on demographics and technology use, Likert scale questions to assess capability, opportunity, and motivation to use DAT and open-ended feedback. We summarized demographic and technology use data descriptively, generated pooled estimates of responses to Likert scale questions within each COM-B category for people with TB and health care workers using random effects models, and performed qualitative analysis of open-ended feedback using a modified framework analysis approach. The analysis included surveys administered to 1290 people with TB and 90 HCWs across 6 TB REACH-funded projects. People with TB and HCWs had an overall positive impression of DATs with pooled estimates between 4·0 to 4·8 out of 5 across COM-B categories. However, 44% of people with TB reported taking TB medications without reporting dosing via DATs and 23% reported missing a dose of medication. Common reasons included problems with electricity, network coverage, and technical issues with the DAT platform. DATs were overall perceived to reduce visits to clinics, decrease cost, increase social support, and decrease workload of HCWs. DATs were acceptable in a wide variety of settings. However, there were challenges related to the feasibility of using current DAT platforms. Implementation efforts should concentrate on ensuring access, anticipating, and addressing technical challenges, and minimizing additional cost to people with TB.