Digital Health Support in Treatment for Tuberculosis

Yoeli, Erez; Rathauser, Jon; Bhanot, Syon; Kimenye, Maureen K; Mailu, Eunice; Masini, Enos; Owiti, Philip; Rand, David G.

doi:10.1056/nejmc1806550

Cited by 49 publications

(47 citation statements)

References 3 publications

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“…We identified some technical challenges with smartphones and uncharged batteries leading to missed video submissions, but most participants were satisfied with using VDOT. These results are consistent with previous studies [27,[30][31][32]38] and add to the evidence base that supports digital health as a promising intervention for supporting TB treatment in African settings [34].…”

Section: Discussionsupporting

confidence: 92%

“…Previous studies in high-income [26,27,[30][31][32] and low-income countries [9,33] have reported high adherence and patient satisfaction with VDOT. One study from Kenya showed the promise of digital health interventions for supporting TB treatment success [34]; however, no published studies exist on the use of VDOT in Africa. The aim of this study was to determine the feasibility and acceptability of VDOT for monitoring and supporting treatment adherence in the Ugandan context.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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IntroductionNonadherence to treatment remains an obstacle to tuberculosis (TB) control worldwide. The aim of this study was to evaluate the feasibility of using video directly observed therapy (VDOT) for supporting TB treatment adherence in Uganda.MethodsFrom May to December 2018, we conducted a pilot cohort study at a TB clinic in Kampala City. We enrolled patients aged 18–65 years with ≥3 months remaining of their TB treatment. Participants were trained to use a smartphone app to record videos of medication intake and submit them to a secured system. Trained health workers logged into the system to watch the submitted videos. The primary outcome was adherence measured as the fraction of expected doses observed (FEDO). In a secondary analysis, we examined differences in FEDO by sex, age, phone ownership, duration of follow-up, reasons for missed videos and patients' satisfaction at study exit.ResultsOf 52 patients enrolled, 50 were analysed. 28 (56%) were male, the mean age was 31 years (range 19–50 years) and 35 (70%) owned smartphones. Of the 5150 videos expected, 4231 (82.2%) were received. The median FEDO was 85% (interquartile range 66%–94%) and this significantly differed by follow-up duration. Phone malfunction, uncharged battery and VDOT app malfunctions were the commonest reasons for missed videos. 92% of patients reported being very satisfied with using VDOT.ConclusionVDOT was feasible and acceptable for monitoring and supporting TB treatment. It resulted in high levels of adherence, suggesting that digital technology holds promise in improving patient monitoring in Uganda.

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Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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“…Consistent with these findings, SMS text messaging reminders alone or two-way SMS text message–based strategies (ie, in which patients send SMS text messages to report doses taken) have been found to be ineffective or less effective than strategies that combine SMS text messages with other interventions to promote TB and HIV medication adherence [ 17 - 22 ]. These findings suggest that reminders and remote monitoring may be insufficient and that strategies that use technology to facilitate human interaction, rather than replacing it, may be more effective in improving medication adherence, a principle supported by recent trials of DATs in TB and HIV care that have had more successful outcomes [ 23 - 25 ].…”

Section: Discussionmentioning

confidence: 99%

Explaining Differences in the Acceptability of 99DOTS, a Cell Phone–Based Strategy for Monitoring Adherence to Tuberculosis Medications: Qualitative Study of Patients and Health Care Providers

Thomas¹,

Kumar²,

Onongaya³

et al. 2020

JMIR Mhealth Uhealth

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Background 99DOTS is a cell phone–based strategy for monitoring tuberculosis (TB) medication adherence that has been rolled out to more than 150,000 patients in India’s public health sector. A considerable proportion of patients stop using 99DOTS during therapy. Objective This study aims to understand reasons for variability in the acceptance and use of 99DOTS by TB patients and health care providers (HCPs). Methods We conducted qualitative interviews with individuals taking TB therapy in the government program in Chennai and Vellore (HIV-coinfected patients) and Mumbai (HIV-uninfected patients) across intensive and continuation treatment phases. We conducted interviews with HCPs who provide TB care, all of whom were involved in implementing 99DOTS. Interviews were transcribed, coded using a deductive approach, and analyzed with Dedoose 8.0.35 software (SocioCultural Research Consultants, LLC). The findings of the study were interpreted using the unified theory of acceptance and use of technology, which highlights 4 constructs associated with technology acceptance: performance expectancy, effort expectancy, social influences, and facilitating conditions. Results We conducted 62 interviews with patients with TB, of whom 30 (48%) were HIV coinfected, and 31 interviews with HCPs. Acceptance of 99DOTS by patients was variable. Greater patient acceptance was related to perceptions of improved patient-HCP relationships from increased phone communication, TB pill-taking habit formation due to SMS text messaging reminders, and reduced need to visit health facilities (performance expectancy); improved family involvement in TB care (social influences); and from 99DOTS leading HCPs to engage positively in patients’ care through increased outreach (facilitating conditions). Lower patient acceptance was related to perceptions of reduced face-to-face contact with HCPs (performance expectancy); problems with cell phone access, literacy, cellular signal, or technology fatigue (effort expectancy); high TB- and HIV-related stigma within the family (social influences); and poor counseling in 99DOTS by HCPs or perceptions that HCPs were not acting upon adherence data (facilitating conditions). Acceptance of 99DOTS by HCPs was generally high and related to perceptions that the 99DOTS adherence dashboard and patient-related SMS text messaging alerts improve quality of care, the efficiency of care, and the patient-HCP relationship (performance expectancy); that the dashboard is easy to use (effort expectancy); and that 99DOTS leads to better coordination among HCPs (social influences). However, HCPs described suboptimal facilitating conditions, including inadequate training of HCPs in 99DOTS, unequal changes in workload, and shortages of 99DOTS medication envelopes. Conclusions In India’s government TB program, 99DOTS had high acceptance by HCPs but variable acceptance by patients. Although some factors contributing to suboptimal patient acceptance are modifiable, other factors such as TB- and HIV-related stigma and poor cell phone accessibility, cellular signal, and literacy are more difficult to address. Screening for these barriers may facilitate targeting of 99DOTS to patients more likely to use this technology.

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“…By designing a hybrid workflow, we were able to integrate the efficiency benefits of automated messaging with the familiarity and flexibility of human-to-human conversational texting. While our usability and acceptability findings are grounded in the clinical and operational particulars of MC, our results are largely attributable to the software and hybrid 2wT workflow rather than to a specific disease or condition, contributing to the growing applicability of 2wT in healthcare interventions in developing countries, including SSA [86][87][88][89]. Similar automated/human-tohuman 2wT merits further study in other care contexts, such as childhood diseases, respiratory infections, or post-operative care that could similarly benefit from intensive, direct providerto-client communication.…”

Section: Discussionmentioning

confidence: 99%

Usability and acceptability of a two-way texting intervention for post-operative follow-up for voluntary medical male circumcision in Zimbabwe

Feldacker

Holeman

Murenje³

et al. 2020

PLoS ONE

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Background Voluntary medical male circumcision (MC) is safe and effective. Nevertheless, MC programs require multiple post-operative visits. In Zimbabwe, a randomized control trial (RCT) found that post-operative two-way texting (2wT) between clients and MC providers instead of in-person reviews reduced provider workload and safeguarded patient safety. A critical component of the RCT assessed usability and acceptability of 2wT among providers and clients. These findings inform scale-up of the 2wT approach to post-operative follow-up. Methods The RCT assigned 362 adult MC clients with cell phones into 2wT; these men responded to 13 automated daily texts supported by interactive texting or in-person follow-up, when needed. A subset of 100 texting clients filled a self-administered usability survey on day 14. 2wT acceptability was ascertained via 2wT response rates. Among 2wT providers, eight key informant interviews focused on 2wT acceptability and usability. Influences of wage and age on response rates and client-reported potential AEs were explored using linear and logistic regression models, respectively. Results Clients felt confident, comfortable, satisfied, and well-supported with 2wT-based follow-up; few noted texting challenges or concerns about healing. Clients felt 2wT saved them time and money. Response rates (92%) suggested 2wT acceptability. Both clients and providers felt 2wT was highly usable. Providers noted 2wT saved them time, empowered clients to

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Digital Health Support in Treatment for Tuberculosis

Cited by 49 publications

References 3 publications

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

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

Explaining Differences in the Acceptability of 99DOTS, a Cell Phone–Based Strategy for Monitoring Adherence to Tuberculosis Medications: Qualitative Study of Patients and Health Care Providers

Usability and acceptability of a two-way texting intervention for post-operative follow-up for voluntary medical male circumcision in Zimbabwe

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