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Nguyen HB, Vo LNQ, Forse RJ, Wiemers AMC, Huynh HB, Dong TTT, Phan YTH, Creswell J, Dang TMH, Nguyen LH, Shedrawy J, Lönnroth K, Nguyen TD, Dinh LV, Annerstedt KS, Codlin AJ. Is convenience really king? Comparative evaluation of catastrophic costs due to tuberculosis in the public and private healthcare sectors of Viet Nam: a longitudinal patient cost study. Infect Dis Poverty 2024; 13:27. [PMID: 38528604 DOI: 10.1186/s40249-024-01196-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/11/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND In Viet Nam, tuberculosis (TB) represents a devastating life-event with an exorbitant price tag, partly due to lost income from daily directly observed therapy in public sector care. Thus, persons with TB may seek care in the private sector for its flexibility, convenience, and privacy. Our study aimed to measure income changes, costs and catastrophic cost incurrence among TB-affected households in the public and private sector. METHODS Between October 2020 and March 2022, we conducted 110 longitudinal patient cost interviews, among 50 patients privately treated for TB and 60 TB patients treated by the National TB Program (NTP) in Ha Noi, Hai Phong and Ho Chi Minh City, Viet Nam. Using a local adaptation of the WHO TB patient cost survey tool, participants were interviewed during the intensive phase, continuation phase and post-treatment. We compared income levels, direct and indirect treatment costs, catastrophic costs using Wilcoxon rank-sum and chi-squared tests and associated risk factors between the two cohorts using multivariate regression. RESULTS The pre-treatment median monthly household income was significantly higher in the private sector versus NTP cohort (USD 868 vs USD 578; P = 0.010). However, private sector treatment was also significantly costlier (USD 2075 vs USD 1313; P = 0.005), driven by direct medical costs which were 4.6 times higher than costs reported by NTP participants (USD 754 vs USD 164; P < 0.001). This resulted in no significant difference in catastrophic costs between the two cohorts (Private: 55% vs NTP: 52%; P = 0.675). Factors associated with catastrophic cost included being a single-person household [adjusted odds ratio (aOR = 13.71; 95% confidence interval (CI): 1.36-138.14; P = 0.026], unemployment during treatment (aOR = 10.86; 95% CI: 2.64-44.60; P < 0.001) and experiencing TB-related stigma (aOR = 37.90; 95% CI: 1.72-831.73; P = 0.021). CONCLUSIONS Persons with TB in Viet Nam face similarly high risk of catastrophic costs whether treated in the public or private sector. Patient costs could be reduced through expanded insurance reimbursement to minimize direct medical costs in the private sector, use of remote monitoring and multi-week/month dosing strategies to avert economic costs in the public sector and greater access to social protection mechanism in general.
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Affiliation(s)
| | - Luan Nguyen Quang Vo
- Friends for International TB Relief, Ha Noi, Viet Nam.
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden.
| | - Rachel Jeanette Forse
- Friends for International TB Relief, Ha Noi, Viet Nam
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | | | - Huy Ba Huynh
- Friends for International TB Relief, Ha Noi, Viet Nam
| | | | | | | | | | | | - Jad Shedrawy
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Knut Lönnroth
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | | | | | - Kristi Sidney Annerstedt
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Andrew James Codlin
- Friends for International TB Relief, Ha Noi, Viet Nam
- Department of Global Public Health, WHO Collaboration Centre On Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
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Kiwanuka N, Kityamuwesi A, Crowder R, Guzman K, Berger CA, Lamunu M, Namale C, Kunihira Tinka L, Nakate AS, Ggita J, Turimumahoro P, Babirye D, Oyuku D, Patel D, Sammann A, Turyahabwe S, Dowdy DW, Katamba A, Cattamanchi A. Implementation, feasibility, and acceptability of 99DOTS-based supervision of treatment for drug-susceptible TB in Uganda. PLOS Digit Health 2023; 2:e0000138. [PMID: 37390077 DOI: 10.1371/journal.pdig.0000138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 05/30/2023] [Indexed: 07/02/2023]
Abstract
99DOTS is a low-cost digital adherence technology that allows people with tuberculosis (TB) to self-report treatment adherence. There are limited data on its implementation, feasibility, and acceptability from sub-Saharan Africa. We conducted a longitudinal analysis and cross-sectional surveys nested within a stepped-wedge randomized trial at 18 health facilities in Uganda between December 2018 and January 2020. The longitudinal analysis assessed implementation of key components of a 99DOTS-based intervention, including self-reporting of TB medication adherence via toll-free phone calls, automated text message reminders and support actions by health workers monitoring adherence data. Cross-sectional surveys administered to a subset of people with TB and health workers assessed 99DOTS feasibility and acceptability. Composite scores for capability, opportunity, and motivation to use 99DOTS were estimated as mean Likert scale responses. Among 462 people with pulmonary TB enrolled on 99DOTS, median adherence was 58.4% (inter-quartile range [IQR] 38.7-75.6) as confirmed by self-reporting dosing via phone calls and 99.4% (IQR 96.4-100) when also including doses confirmed by health workers. Phone call-confirmed adherence declined over the treatment period and was lower among people with HIV (median 50.6% vs. 63.7%, p<0.001). People with TB received SMS dosing reminders on 90.5% of treatment days. Health worker support actions were documented for 261/409 (63.8%) people with TB who missed >3 consecutive doses. Surveys were completed by 83 people with TB and 22 health workers. Composite scores for capability, opportunity, and motivation were high; among people with TB, composite scores did not differ by gender or HIV status. Barriers to using 99DOTS included technical issues (phone access, charging, and network connection) and concerns regarding disclosure. 99DOTS was feasible to implement and highly acceptable to people with TB and their health workers. National TB Programs should offer 99DOTS as an option for TB treatment supervision.
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Affiliation(s)
- Noah Kiwanuka
- Department of Epidemiology & Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Alex Kityamuwesi
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Rebecca Crowder
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Kevin Guzman
- Department of Medicine, University of California San Francisco, San Francisco, California, United States
| | - Christopher A Berger
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Maureen Lamunu
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Catherine Namale
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Lynn Kunihira Tinka
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Agnes Sanyu Nakate
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Joseph Ggita
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | | | - Diana Babirye
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Denis Oyuku
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Devika Patel
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Amanda Sammann
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Stavia Turyahabwe
- Uganda National Tuberculosis and Leprosy Programme, Ministry of Health, Kampala, Uganda
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Achilles Katamba
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Adithya Cattamanchi
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
- Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, California, United States of America
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Leddy A, Ggita J, Berger C, Kityamuwesi A, Nakate AS, Tinka LK, Crowder R, Turyahabwe S, Katamba A, Cattamanchi A. Barriers and facilitators to implementing a digital adherence technology for tuberculosis treatment supervision in Uganda: A qualitative study (Preprint). J Med Internet Res 2022; 25:e38828. [DOI: 10.2196/38828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 09/22/2022] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
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Cattamanchi A, Crowder R, Kityamuwesi A, Kiwanuka N, Lamunu M, Namale C, Tinka LK, Nakate AS, Ggita J, Turimumahoro P, Babirye D, Oyuku D, Berger C, Tucker A, Patel D, Sammann A, Turyahabwe S, Dowdy D, Katamba A. Digital adherence technology for tuberculosis treatment supervision: A stepped-wedge cluster-randomized trial in Uganda. PLoS Med 2021; 18:e1003628. [PMID: 33956802 PMCID: PMC8136841 DOI: 10.1371/journal.pmed.1003628] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/20/2021] [Accepted: 04/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Adherence to and completion of tuberculosis (TB) treatment remain problematic in many high-burden countries. 99DOTS is a low-cost digital adherence technology that could increase TB treatment completion. METHODS AND FINDINGS We conducted a pragmatic stepped-wedge cluster-randomized trial including all adults treated for drug-susceptible pulmonary TB at 18 health facilities across Uganda over 8 months (1 December 2018-31 July 2019). Facilities were randomized to switch from routine (control period) to 99DOTS-based (intervention period) TB treatment supervision in consecutive months. Patients were allocated to the control or intervention period based on which facility they attended and their treatment start date. Health facility staff and patients were not blinded to the intervention. The primary outcome was TB treatment completion. Due to the pragmatic nature of the trial, the primary analysis was done according to intention-to-treat (ITT) and per protocol (PP) principles. This trial is registered with the Pan African Clinical Trials Registry (PACTR201808609844917). Of 1,913 eligible patients at the 18 health facilities (1,022 and 891 during the control and intervention periods, respectively), 38.0% were women, mean (SD) age was 39.4 (14.4) years, 46.8% were HIV-infected, and most (91.4%) had newly diagnosed TB. In total, 463 (52.0%) patients were enrolled on 99DOTS during the intervention period. In the ITT analysis, the odds of treatment success were similar in the intervention and control periods (adjusted odds ratio [aOR] 1.04, 95% CI 0.68-1.58, p = 0.87). The odds of treatment success did not increase in the intervention period for either men (aOR 1.24, 95% CI 0.73-2.10) or women (aOR 0.67, 95% CI 0.35-1.29), or for either patients with HIV infection (aOR 1.51, 95% CI 0.81-2.85) or without HIV infection (aOR 0.78, 95% CI 0.46-1.32). In the PP analysis, the 99DOTS-based intervention increased the odds of treatment success (aOR 2.89, 95% CI 1.57-5.33, p = 0.001). The odds of completing the intensive phase of treatment and the odds of not being lost to follow-up were similarly improved in PP but not ITT analyses. Study limitations include the likelihood of selection bias in the PP analysis, inability to verify medication dosing in either arm, and incomplete implementation of some components of the intervention. CONCLUSIONS 99DOTS-based treatment supervision did not improve treatment outcomes in the overall study population. However, similar treatment outcomes were achieved during the control and intervention periods, and those patients enrolled on 99DOTS achieved high treatment completion. 99DOTS-based treatment supervision could be a viable alternative to directly observed therapy for a substantial proportion of patients with TB. TRIAL REGISTRATION Pan-African Clinical Trials Registry (PACTR201808609844917).
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Affiliation(s)
- Adithya Cattamanchi
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
- * E-mail:
| | - Rebecca Crowder
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Alex Kityamuwesi
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maureen Lamunu
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Catherine Namale
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Lynn Kunihira Tinka
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Agnes Sanyu Nakate
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Joseph Ggita
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | | | - Diana Babirye
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Denis Oyuku
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Christopher Berger
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Austin Tucker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Devika Patel
- The Better Lab, Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Amanda Sammann
- The Better Lab, Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Stavia Turyahabwe
- National Tuberculosis and Leprosy Program, Uganda Ministry of Health, Kampala, Uganda
| | - David Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
- Clinical Epidemiology and Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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Patel D, Berger CA, Kityamuwesi A, Ggita J, Kunihira Tinka L, Turimumahoro P, Feler J, Chehab L, Chen AZ, Gupta N, Turyahabwe S, Katamba A, Cattamanchi A, Sammann A. Iterative Adaptation of a Tuberculosis Digital Medication Adherence Technology to Meet User Needs: Qualitative Study of Patients and Health Care Providers Using Human-Centered Design Methods. JMIR Form Res 2020; 4:e19270. [PMID: 33289494 PMCID: PMC7755538 DOI: 10.2196/19270] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/29/2020] [Accepted: 09/24/2020] [Indexed: 12/25/2022] Open
Abstract
Background Digital adherence technologies have been widely promoted as a means to improve tuberculosis medication adherence. However, uptake of these technologies has been suboptimal by both patients and health workers. Not surprisingly, studies have not demonstrated significant improvement in treatment outcomes. Objective This study aimed to optimize a well-known digital adherence technology, 99DOTS, for end user needs in Uganda. We describe the findings of the ideation phase of the human-centered design methodology to adapt 99DOTS according to a set of design principles identified in the previous inspiration phase. Methods 99DOTS is a low-cost digital adherence technology wherein tuberculosis medication blister packs are encased within an envelope that reveals toll-free numbers that patients can call to report dosing. We identified 2 key areas for design and testing: (1) the envelope, including the form factor, content, and depiction of the order of pill taking; and (2) the patient call-in experience. We conducted 5 brainstorming sessions with all relevant stakeholders to generate a suite of potential prototype concepts. Senior investigators identified concepts to further develop based on feasibility and consistency with the predetermined design principles. Prototypes were revised with feedback from the entire team. The envelope and call-in experience prototypes were tested and iteratively revised through focus groups with health workers (n=52) and interviews with patients (n=7). We collected and analyzed qualitative feedback to inform each subsequent iteration. Results The 5 brainstorming sessions produced 127 unique ideas that we clustered into 6 themes: rewards, customization, education, logistics, wording and imagery, and treatment countdown. We developed 16 envelope prototypes, 12 icons, and 28 audio messages for prototype testing. In the final design, we altered the pill packaging envelope by adding a front flap to conceal the pills and reduce potential stigma associated with tuberculosis. The flap was adorned with either a blank calendar or map of Uganda. The inside cover contained a personalized message from a local health worker including contact information, pictorial pill-taking instructions, and a choice of stickers to tailor education to the patient and phase of treatment. Pill-taking order was indicated with colors, chevron arrows, and small mobile phone icons. Last, the call-in experience when patients report dosing was changed to a rotating series of audio messages centered on the themes of prevention, encouragement, and reassurance that tuberculosis is curable. Conclusions We demonstrated the use of human-centered design as a promising tool to drive the adaptation of digital adherence technologies to better address the needs and motivations of end users. The next phase of research, known as the implementation phase in the human-centered design methodology, will investigate whether the adapted 99DOTS platform results in higher levels of engagement from patients and health workers, and ultimately improves tuberculosis treatment outcomes.
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Affiliation(s)
- Devika Patel
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Christopher Allen Berger
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California, San Francisco, San Francisco, CA, United States
| | - Alex Kityamuwesi
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Joseph Ggita
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | | | | | - Joshua Feler
- School of Medicine, Yale University, New Haven, CA, United States
| | - Lara Chehab
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Amy Z Chen
- Everwell Health Solutions, Bangalore, India
| | | | | | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda.,Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California, San Francisco, San Francisco, CA, United States.,Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Amanda Sammann
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
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