Incentives and enablers to improve adherence in tuberculosis

Abstract

Background Patient adherence to medications, particularly for conditions requiring prolonged treatment such as tuberculosis (TB), is frequently less than ideal and can result in poor treatment outcomes. Material incentives to reward good behaviour and enablers to remove economic barriers to accessing care are sometimes given in the form of cash, vouchers, or food to improve adherence. Objectives To evaluate the effects of material incentives and enablers in patients undergoing diagnostic testing, or receiving prophylactic or curative therapy, for TB. Search methods We undertook a comprehensive search of the Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; LILACS; Science Citation Index; and reference lists of relevant publications up to 5 June 2015. Selection criteria Randomized controlled trials of material incentives in patients being investigated for TB, or on treatment for latent or active TB. Data collection and analysis At least two review authors independently screened and selected studies, extracted data, and assessed the risk of bias in the included trials. We compared the effects of interventions using risk ratios (RR), and presented RRs with 95% confidence intervals (CI). The quality of the evidence was assessed using GRADE. Main results We identified 12 eligible trials. Ten were conducted in the USA: in adolescents (one trial), in injection drug or cocaine users (four trials), in homeless adults (three trials), and in prisoners (two trials). The remaining two trials, in general adult populations, were conducted in Timor‐Leste and South Africa. Sustained incentive programmes Only two trials have assessed whether material incentives and enablers can improve long‐term adherence and completion of treatment for active TB, and neither demonstrated a clear benefit (RR 1.04, 95% CI 0.97 to 1.14; two trials, 4356 participants; low quality evidence ). In one trial, the incentive, given as a daily hot meal, was not well received by the population due to the inconvenience of attending the clinic at midday, whilst in the other trial, nurses distributing the vouchers chose to "ration" their distribution among eligible patients, giving only to those whom they felt were most deprived. Three trials assessed the effects of material incentives and enablers on completion of TB prophylaxis with mixed results ( low quality evidence ). A large effect was seen with regular cash incentives given to drug users at each clinic visit in a setting with extremely low treatment completion in the control group (treatment completion 52.8% intervention versus 3.6% control; RR 14.53, 95% CI 3.64 to 57.98; one trial, 108 participants), but no effects were seen in one trial assessing a cash incentive for...

Effects of social protection on tuberculosis treatment outcomes in low or middle-income and in high-burden countries: systematic review and meta-analysis

“…They can be implemented in different ways, such as material incentives, cash transfers or food security programs 1 . Evidences from RCTs conducted in the United States show that incentives can contribute to patient attendance in TB health care facilities, improving treatment adherence 46 .…”

Implementation strategies for health systems in low-income countries: an overview of systematic reviews

“…We used the methods described below in all four overviews of health system arrangements and implementation strategies in low-income countries (Ciapponi 2014;Herrera 2014;Wiysonge 2014).…”

“…Fifteen of the reviews were updates of earlier reviews (Baker 2015;Berkman 2011;Everett 2011;Forsetlund 2009;Giguère 2012;Gould 2010;Haynes 2008;Horsley 2011;Ivers 2012;Liu 2014;Lutge 2015;O'Brien 2007;Oyo-Ita 2016;Reeves 2013;Sibley 2012). The reviews reported results from 1332 studies (Appendix 3).…”

“…Immediate (compared to deferred) incentives may not improve adherence to anti-tuberculosis treatment (low-certainty evidence). The second review assessed the effects of reminder systems aimed at reminding patients to take their TB medication or attend appointments (pre-appointment reminders) or to contact patients who have missed an appointment with default reminders (Liu 2014). The review included six trials of pre-appointment reminders and three trials of default reminders.…”

“…However, there are a limited number of interventions in the included reviews where most of the evidence is from low-and middle-income countries and are likely to be applicable to low-income countries. This may be the case for free insecticide-treated bednets for malaria prevention (Augustincic Polec 2015), skilled birth attendance (Yakoob 2011), mobile phone messaging to improve adherence to ART (Mbuagbaw 2013), anti-malarial drugs packed in unit doses (Orton 2005), and hand-hygiene interventions (Gould 2010).…”