Public health specialists in Uganda are pushing for a Smartphone-based approach as an alternative in Tuberculosis (TB) treatment adherence, after a study in Kampala found compliance rate at about 90 percent among those using VDOT, along with high patient satisfaction rates compared to 30 percent in the usual care group.
A study dubbed ‘DOT Selfie’ also known as Video Directly Observed Therapy or VDOT was conducted among 144 randomly selected tuberculosis (TB) in six TB clinics around Kampala. The clinics included Kisenyi, Kitebi, and Kawaala health centers alongside Lubaga, Mulago, and Mengo Hospitals.
‘DOT Selfie’ method allows for remote treatment monitoring through patient-recorded videos through a smartphone app showing their daily medication intake. The patients then submit the videos to the health system for review by health workers for monitoring treatment adherence compared to Usual Care DOT (UCDOT).
The method is promising as a flexible and less invasive option to help ensure TB patients complete their treatment successfully.
Currently, directly observed therapy (DOT) for treatment adherence monitoring is the recommended standard. But research has shown that it is challenging to implement at scale because it is labor-intensive.
The study results show that there was limited adherence to treatment from among the patients that were enrolled on the usual care, with adherence at just 9.9 percent. Some of the study participants highlighted the lack of treatment supporters in the Usual Care DOT as well as the stigma associated with health worker visits.
Dr. Juliet Nabuye Sekandi the study Principal Investigator notes that the study was motivated by fact that tuberculosis (TB) is treatable and curable only if patients take their medication. The mobile phone-based interventions to improve patient adherence have been tried out in other countries especially in the U.S. and in India.
The DOT Selfie study conducted in Uganda sought to evaluate the effectiveness of using Video Directly Observed Treatment (VDOT) to improve medication adherence in TB treatment versus usual care DOT in an African context.
Uganda remains among the high TB/HIV burden countries in the world. The first national population-based TB disease prevalence survey in 2014/15 estimated the prevalence of TB at 253 cases in every 100,000 people. The survey also showed that Tuberculosis caused 80,000 new cases much higher than HIV (60,000 new cases).
The WHO’s post-2015, End TB Strategy adopted by the World Health Assembly in 2014, aims to end the global TB epidemic as part of the newly adopted Sustainable Development Goals. It serves as a blueprint for countries to reduce TB incidence by 80%, TB deaths by 90%, and to eliminate catastrophic costs for TB-affected households by 2030.
Throughout the last decade, tuberculosis (TB) treatment success has not surpassed 90%, the global target. Dr. Sekandi observes that poor medication adherence is likely to increase rates of loss to follow-up, disease relapse and drug resistance for individuals with active TB.
“What we see in routine care is that patients sometimes forget to take their medicine, they get tired and get off medicine maybe after a month or two because TB treatment is for six months,” she discloses.
Dr. Sekandi who is also an Assistant Professor, Department of Epidemiology & Biostatistics & Global Health Institute at the University of Georgia in the United States observes that this particular study is aimed to improve adherence to medication to ensure that patients can take advantage of medicine that actually cure their TB.
“That is why we have invested this time to research on a new method to try and help the patients to take their medicines completely and efficiently,” said Dr. Sekandi.
The findings of the study show digital adherence technologies like VDOT can play a positive role in delivering patient-centered TB care. Also, patients using VDOT were at least 8 times more likely to have favorable adherence as measured by observation of medication compared to patients using usual care DOT.
The coronavirus pandemic and the subsequent impacts such as lockdowns further underscored the importance of the usage of mobile Health (mHealth) tools.
“This is the perfect timing to think about a method like this that is technology-based. This method started way before Covid-19, but the pandemic has been a catalyst for us to begin to realize that the remote methods of patient care are necessary because lockdowns, no travel, people were in their homes but they could still be able to interact with healthcare providers and get the support that they need like the face-to-face interactions. I would say COVID has helped us to accelerate and improve the methods that we have in our hands,” says Dr. Sekandi.
The study lead team included Dr. Sekandi and Dr. Esther Buregyeya, an Associate Professor, Department of Disease Control & Environmental Health MakSPH as study Principal Investigators. The core research team lead was Ms. Damalie Nakkonde. Others on the team are Mr. Patrick Kaggwa IT specialist, Ms. Daphine Kyaine, Mrs. Gloria Nassanga Kabanda, and Ms. Michelle C. Geno all Research Assistants.
In their findings, the study team observed that patients who owned cellphones were more likely to have a higher level of adherence regardless of study arm. Also, findings suggest that the VDOT intervention is a strong facilitator of social support for TB patients and that small incentives to patients motivate adherence to treatment.
During this intervention study, each participant received a Smartphone with a VDOT App, SMS text reminders for medication intake, a weekly internet bundle of 400MBs, and a weekly airtime incentive of Uganda Shillings 1,000.
Dr. Sarah Zalwango, the Kampala Capital City Authority (KCCA) Manager Medical Services and a Clinical Director, VDOT Study says this method will offer flexibility and is good for low-resource settings.
“What we do as health workers, we have the Direct Observed Therapy where the patient is observed physically while swallowing the medicine. So, if you have this option of doing it in your own space, and you do not have to move to be observed and have a treatment supporter of course it will come a long way in helping to save on many things; transport, [human resource] constraints,” says Dr. Zalwango.
Elsewhere, studies have shown that Digital adherence technologies (DATs)—have the potential to facilitate more patient-centered care for monitoring TB medication adherence than the existing standard of care; directly observed therapy (DOT) models.
According to Dr. Zalwango, VDOT fits well into the TB / Leprosy Control Program (NTLP) recently agreed strategy of patient-centered care. She notes that since the National TB Program is currently piloting the same method in other districts across the country, it will be a game-changer in monitoring treatment adherence as well as improved outcomes.
“It will go a long way leave alone the challenges it comes with which includes smartphones, data availability but for those that can have access to that, it will help that portion so that they take that option and they don’t have to enroll in the directly observed therapy,” Dr. Zalwango.
“I appreciate all the researchers for the great work well done in the DOT selfie study, in particular, I want to recognize Dr Esther Buregyeya from Makerere School of Public Health, who was the local PI, Dr Juliet Sekandi from the University of Georgia, who was our lead PI the national TB and Leprosy program for technical support and Lubaga hospital for providing a home for the study”, the study wouldn’t have been possible without your efforts,” she adds.
How VDOT works
Mr. Patrick Kaggwa, a health informatics specialist on the program explains that each participant enrolled on the VDOT-Selfie study was required to use a smartphone to record and send time-stamped encrypted videos showing his/her daily medication ingestion.
He notes that video directly substitutes the need for daily face-to-face meetings between the health provider and patient.
“During this study, each patient was given a smartphone with the app, whereby every morning, the patient would take videos and this would be sent to the web-based system. This was done to ensure that the health workers observe the video and tell whether the patient took their medicine and all this helped to document adherence,” says Kaggwa.
“The system is automatically designed to review videos, document adherence, and also document side effects in the medication videos,” he adds.
Kaggwa also notes that the study had a messaging system where patients would receive translated messages as reminders to patients to take their medicine. This was in addition to the mobile-phone-based ‘social bundle’ incentives to motivate adherence to continued daily submission of videos to the health system.
Limitations
Muwanguzi (not real name), one of the TB patients being monitored in one of the facilities said during a dissemination workshop held in December 2021 at Pope Paul 11 Memorial Hotel in Kampala says it was very hard for him to take the videos from his workplace.
“I remember the first time to take a video, I had to deceive my boss that I was undertaking some other treatment because I thought they would stigmatize me so much at workplace”. He noted.
Besides giving feedback to health workers, Muwanguzi says the VDOT app helped him not to hide his illness.
“Months before getting TB treatment, I had tested HIV positive but I had reached a point of ignoring my daily ARVs but when I got the smartphone, I was able to record myself taking all my medicine as prescribed by health workers,” he testified.
Mr. Vincent Kasiita, a qualitative researcher at MakSPH says from in-depth interviews conducted among health workers from KCCA clinics, several health workers viewed the use of the VDOT method as increased workload especially if not well-trained signaling recruitment of more health workers to review these videos.
According to Kasiita, some TB clinics had no computers to use for the VDOT practical trials. For the side of patients, he says; “It was difficult for some of them to operate smartphones since most of these participants were of less or had no education as one patient had to say; “I have never operated even an ordinary small phone, how will I be able to learn using a smartphone and use it to take daily videos”.
He avers that other patients were very scared of recording their videos and submitting them for fear of their videos being used in adverts as one patient said, “what if I find my video being used in an advert?”.
However, Kasiita observes that the VDOT method is patient and evidence-centered. He cites the availability of video evidence of taking medication.
“We want patients to be at the center of their healthcare unlike before when we depended mostly on treatment supporters that have been policing patients,” he said policymakers.
Researchers recommend the provision of incentives to motivate TB medication adherence. They also recommend community sensitization of TB to minimize TB patient stigmatization.
