Digital Adherence Research Articles

Data Control and Surveillance in the Global TB Response: A Human Rights Analysis

The global response to the tuberculosis (TB) epidemic is generating copious amounts of personal health data. The emerging emphasis on the use of active case finding and digital adherence technologies in the TB response will increase the amount and expand the kind of data produced and used by public and private health officials. The production of personal data in high TB burden countries, in particular, must be considered in light of their colonial histories. In doing so, we argue that interventions to eliminate TB at global and national levels are ushering in a new era of data colonisation and surveillance in the name of public health. This, in turn, raises critical concerns for the human rights of people affected by TB, many of whom belong to vulnerable or marginalised groups. We examine the normative and legal content for a set of international human rights critical to the TB response, highlighting how each right implicates the production and use of personal health data. We also demonstrate that these rights are, by and large, enshrined in the constitutions of each high TB burden country. Finally, we use these rights to analyse active case finding and digital adherence technologies to pinpoint their unique data risks and the threats they pose to the human rights of people affected by TB.

Data Control and Surveillance in the Global TB Response: A Human Rights Analysis

The global response to the tuberculosis (TB) epidemic is generating copious amounts of personal health data. The emerging emphasis on the use of active case finding and digital adherence technologies in the TB response will increase the amount and expand the kind of data produced and used by public and private health officials. The production of personal data in high TB burden countries, in particular, must be considered in light of their colonial histories. In doing so, we argue that interventions to eliminate TB at global and national levels are ushering in a new era of data colonisation and surveillance in the name of public health. This, in turn, raises critical concerns for the human rights of people affected by TB, many of whom belong to vulnerable or marginalised groups. We examine the normative and legal content for a set of international human rights critical to the TB response, highlighting how each right implicates the production and use of personal health data. We also demonstrate that these rights are, by and large, enshrined in the constitutions of each high TB burden country. Finally, we use these rights to analyse active case finding and digital adherence technologies to pinpoint their unique data risks and the threats they pose to the human rights of people affected by TB.

Temporal Factors and Missed Doses of Tuberculosis Treatment. A Causal Associations Approach to Analyses of Digital Adherence Data.

Rationale: Tuberculosis treatment lasts for 6 months or more. Treatment adherence is critical; regimen length, among other factors, makes this challenging. Globally, analyses mapping common types of nonadherence are lacking. For example, is there a greater challenge resulting from early treatment cessation (discontinuation) or intermittent missed doses (suboptimal dosing implementation)? This is essential knowledge for the development of effective interventions and more “forgiving” regimens, as well as to direct national tuberculosis programs.Objectives: To granularly describe how patients take their tuberculosis medication and the temporal factors associated with missed doses.Methods: The present study included patients with pulmonary tuberculosis enrolled in the control arm of a pragmatic, cluster-randomized trial in China of electronic reminders to improve treatment adherence. Treatment was the standard 6-month course (180 d), dosed every other day (90 doses). Medication monitor boxes recorded adherence (box opening) without prompting reminders. Patterns of adherence were visualized and described. Mixed-effects logistic regression models examined the temporal factors associated with per-dose suboptimal dosing implementation, adjusting for clustering within a participant. Cox regression models were used to examine the association between early suboptimal dosing implementation and permanent discontinuation.Results: Across 780 patients, 16,794 (23.9%) of 70,200 doses were missed, 9,487 of which were from suboptimal dosing implementation (56.5%). By 60 days, 5.1% of participants had discontinued, and 14.4% had discontinued by 120 days. Most participants (95.9%) missed at least one dose. The majority of gaps were of a single dose (71.4%), although 22.6% of participants had at least one gap of 2 weeks or more. In adjusted models, the initiation–continuation phase transition (odds ratio, 3.07 [95% confidence interval, 2.68–3.51]) and national holidays (1.52 [1.39–1.65]) were associated with increased odds of suboptimal dosing implementation. Early-stage suboptimal dosing implementation was associated with increased discontinuation rates.Conclusions: Digital tools provide an unprecedented step change in describing and addressing nonadherence. In our setting, nonadherence was common; patients displayed a complex range of patterns. Dividing nonadherence into suboptimal dosing implementation and discontinuation, we found that both increased over time. Discontinuation was associated with early suboptimal dosing implementation. These apparent causal associations between temporal factors and nonadherence present opportunities for targeted interventions.Clinical trial registered with the ISRCTN Registry (ISRCTN46846388).

Digital Competencies and Attitudes Toward Digital Adherence Solutions Among Elderly Patients Treated With Novel Anticoagulants: Qualitative Study.

BackgroundNonadherence to medication is a driver of morbidity and mortality, and complex medication regimens in patients with chronic diseases foster the problem. Digital technology might help, but despite numerous solutions being developed, none are currently widely used, and acceptance rates remain low, especially among the elderly.ObjectiveThis study aimed to better understand and operationalize how new digital solutions can be evaluated. Particularly, the goal was to identify factors that help digital approaches targeting adherence to become more widely accepted.MethodsA qualitative study using a conceptual grounded theory approach was conducted. We included patients aged 65 years and older who routinely took new oral anticoagulants. To generate theses about the digital competencies of the target group with daily medication intake, face-to-face interviews were conducted, recorded, and anonymized. After coding the interviews, categories were generated, discussed, and combined with several theses until saturation of the statements was reached.ResultsThe methodological approach led to the finding that after interviews in 20 of 77 potentially available patients, a saturation of statements was reached. The average patient’s age was 75 years, and 50% (10/20) of the subjects were female. The data identified five main coding categories—Diseases and medicine, Technology, Autonomy, Patient narrative, and Attitude toward technologies—each including positive and negative subcategories. Main categories and subcategories were summarized as Adherence Radar, which can be considered as a framework to assess the potential of adherence solutions in the process of prototyping and can be applied to all adherence tools in a holistic manner.ConclusionsThe Adherence Radar can be used to increase the acceptance rate of digital solutions targeting adherence. For a patient-centric design, an app should be adapted to the individual patient’s needs. According to our results, this application should be based on gender and educational background as well as the individual physician-patient relationship. If used in a proper, individualized manner, digital adherence solutions could become a new cornerstone for the treatment of chronically ill individuals.

Subjective Areas of Improvement: A Personalized Recommendation

Abstract Gen Z-ers, being independent, self-confident and autonomous as their key characteristics are proven to be technologically more advanced than their previous generations. To reach the milestone of understanding and satisfying the Gen-Z community, and to make use of the digital adherence of this generation, a personalized recommender system using machine learning is designed that can recommend the areas which the students should strengthen themselves to lead and be distinct among their peers. The proposed work uses Support Vector Machine to predict the area of improvement which the student need to focus on. The proposed system will also recommend the list of online courses and materials that the users can make use of to strengthen themselves. The model is built using Python flask and Jupyter notebook and is tested using one public dataset and a private dataset. The results are convincing and accurate enough in identifying the proper areas that require improvement.

Ensuring tuberculosis treatment adherence with a mobile-based CARE-call system in Thailand: a pilot study

Background: Medication non-adherence in tuberculosis (TB) patients is an obstacle to TB treatment. Directly observed treatment to monitor and ensure adherence still has some limitations in high TB-burden countries. Most digital adherence technologies emphasize medication-taking reminder functions; however, a bi-directional communication platform to provide patient-health workers with an interface that focuses on enhancing medication adherence is likely to improve medical adherence. A budgeted mobile-based system called CARE-call providing both functions was developed and evaluated concerning whether it could enhance medication adherence.Design: Mixed methods combined quantitative and qualitative approaches. One hundred TB patients were randomized into intervention or control groups. Medication adherence rates between the two groups were compared. A focus group discussion was conducted to obtain in-depth perspectives from the patients.Results: At a 90% adherence level, the number of non-adherence patients in the intervention group was significantly lower than that of the control group (7.5% vs. 27.5%, p= .037). The participants were satisfied with the functions provided by the system, especially the confidentiality of the monitoring process, which did not involve monitoring by imaging or video recording. The bi-directional communication enabled them to contact health staff when concerns arose during the treatment course. Poor mobile phone signals and fast battery drain were reported as major technical problems of the system.Conclusions: The CARE-call system was able to prevent non-adherence in this rural setting in Thailand. However, further investigation with a larger sample size should be conducted on whether the system can also improve successful TB treatment outcome.

Digital monitoring technologies could enhance tuberculosis medication adherence in Uganda: Mixed methods study

BackgroundEffective administration of tuberculosis therapy remains challenging. The recommended strategy of direct observed therapy is challenging and its implementation has been limited in many settings. Digital adherence technologies could be promising patient-centered strategies for monitoring adherence. However, few quality studies have assessed patients’ experiences with these technologies. ObjectiveTo explore TB patients’ perceptions of a digital adherence intervention composed of a digital adherence monitor and SMS texts. MethodsWe purposively sampled TB patients who owned phones, had been taking TB medication for at least a month, and were receiving their treatment from Mbarara Regional Referral Hospital. We interviewed 35 TB patients to elicit information on perceptions of the proposed intervention which electronically monitors how they take their medication, and sends SMS reminders to patients to help them take their medications, as well as send SMS notifications to patients’ social supporters to provide the patient with assistance if possible. We inductively analyzed data using content analysis to derive categories describing how participants perceived the intervention. ResultsParticipants anticipated that the intervention would enhance medication adherence by reminding them to take medication, and helping in the management of complicated regimen. Participants felt that monitoring adherence could enable them to demonstrate their commitment to adherence. Participants expressed concerns about not seeing the SMS on time and unintended TB status disclosure. ConclusionDigital adherence technologies may provide acceptable alternative approaches to monitoring TB medication, especially in settings where DOT is difficult to implement.

Implementation and effectiveness of evriMED with short messages service (SMS) reminders and tailored feedback compared to standard care on adherence to treatment among tuberculosis patients in Kilimanjaro, Tanzania: proposal for a cluster randomized controlled trial

BackgroundAdherence to tuberculosis (TB) treatment is challenging because of many factors. The World Health Organization has recommended the use of digital adherence monitoring technologies in its End TB Strategy. However, evidence on improving adherence is limited. EvriMED is a real-time medication-monitoring device which was found to be feasible and acceptable in a few studies in Asia. In Tanzania, however, there may be challenges in implementing evriMED due to stigmatization, network and power access, accuracy, and cost effectiveness, which may have implications for treatment outcome. We propose a pragmatic cluster randomized trial to investigate the effectiveness of evriMED with reminder cues and tailored feedback on adherence to TB treatment in Kilimanjaro, Tanzania.Methods/designWe will create clusters in Kilimanjaro based on level of health care facility. Clusters will be randomized in an intervention arm, where evriMED will be implemented, or a control arm, where standard practice directly observed treatment will be followed. TB patients in intervention clusters will take their medication from the evriMED pillbox and receive tailored feedback. We will use the ‘Stages of Change’ model, which assumes that a person has to go through the stages of pre-contemplation, contemplation, preparation, action, and evaluation to change behavior for tailored feedback on adherence reports from the device.DiscussionIf the intervention shows a significant effect on adherence and the devices are accepted, accurate, and sustainable, the intervention can be scaled up within the National Tuberculosis Programmes.Trial registrationPan African Clinical Trials Registry, PACTR201811755733759. Registered on 8 November 2018.

P432 How physiotherapists improved prescription accuracy for nebuliser treatment: using click analytics from CFHealthHub, a digital adherence system, to monitor quality improvement

P432 How physiotherapists improved prescription accuracy for nebuliser treatment: using click analytics from CFHealthHub, a digital adherence system, to monitor quality improvement

Perceptions of drones, digital adherence monitoring technologies and educational videos for tuberculosis control in remote Madagascar: a mixed-method study protocol

IntroductionPoor road and communication infrastructure pose major challenges to tuberculosis (TB) control in many regions of the world. TB surveillance and patient support often fall to community health workers (CHWs)...

Exploring the relationship of digital information sources and medication adherence

We present a retrospective analysis of data collected in the United States from the 2015 National Consumer Survey on the Medication Experience and Pharmacists’ Role in order to model the relationship between health information sources and medication adherence and perception. Our results indicate that while the digital age has presented prescription users with many non-traditional alternatives for health information, the use of digital content has a significant negative correlation with pharmaceutical adherence and attitudes toward medication. These findings along with previous research suggest that in order to fully realize the potential benefits of the digital age in regards to patient health, positive patient-provider discussions regarding information found online, efforts to improve general health literacy and improvements in the quality and accuracy of the information found are key. Given that higher reliance on digital content is correlated with younger age, the analysis suggests that proactive measures should be taken to educate younger prescription users about the merits and pitfalls of information seeking techniques as they pertain to health literacy.

EFFICACY OF A CENTRALIZED, BLENDED ELECTRONIC, AND HUMAN INTERVENTION TO IMPROVE DOAC ADHERENCE: THE SMARTADHERE TRIAL

Improving adherence to direct oral anticoagulants (DOAC) is challenging. Simple text-messaging has been ineffective. SmartADHERE was a randomized trial testing a blended digital+human DOAC adherence intervention compared to usual care: a medication management app (Care4Today®), daily app-based

15. Positively Connected For Health (PC4H): Acceptability And Feasibility of A Digital Health Adherence And Engagement In Care Intervention For Adolescents And Young Adults Living With HIV

Adolescents and young adults (AYA) are disproportionately affected by HIV and fewer than half of AYA who are prescribed antiretroviral therapy (ART) achieve viral suppression. Digital interventions can be uniquely designed to provide support and feedback in real time as youth go about their daily lives in order to improve health literacy and ART adherence. The purpose of this study was to determine acceptability, feasibility, and preliminary efficacy of a digital health literacy workshop coupled with a medication adherence application (app) for AYA living with HIV over a 3-month period. Demonstration project (June 2017-July 2018) of AYA 14-34 years old in Philadelphia, PA linked to care at one of five health clinics who are HIV-positive, have an unsuppressed viral load (≥200 copies/ml), and/or have been out of care for ≥6 months last 24 months, and/or newly diagnosed with HIV in last 12 months. The eHealth Literacy Scale (eHEALS) was administered prior to the workshop and at the 3-month follow-up to compare confidence in navigating digital health information. Participant satisfaction was measured via electronic surveys immediately following the workshop and after 3 months of app usage. Self-reported adherence to antiretroviral therapy (ART), by visual analog scale (VAS) for past month adherence, and viral load from electronic health records were measured at baseline and 3-month follow-up. Descriptive analyses were performed and t tests for paired samples were used to compare baseline and 3-month outcomes. Analyses performed using SPSS 24. Participants (N = 41) at workshop/baseline were mean age 25.49 years (SD 4.65, range 17–34), and majority were male (73.17%), Black (73.17%), non-Hispanic/Latino (85.37%), and on ART (97.6%). Most participants (31; 75.61%) were retained at the 3-month study visit where all were still on ART and refilled ART at least once. Among 31 participants who completed eHEALs pre-workshop and 3-months post-workshop, confidence in navigating digital health information to make health decisions among respondents increased from 48.39% (15 agreed) to 70.97% (22 agreed). Of 41 participants at baseline, 92.68% (38) said the workshop helped them navigate and more likely use the app, and 85.37% (35) said the instructor knew the subject matter well. After 3 months of app usage (n=31), 61.29% (19) reported that the app helped them miss fewer doses of ART and 80.65% (25) thought the app made them more likely to call their healthcare provider with questions. Medication and appointment reminders with progress calendar were listed as the most useful app features. Self-report adherence improved (mean VAS baseline=75.19 and 3-month=89.27, p=0.02), but there was no significant difference in viral load (n=28; mean baseline=9473.36 and 3-months=7298.43, p=0.44). Study showed high satisfaction with a digital health literacy workshop and medication adherence app, high retention rates, improved confidence in digital health literacy, and self-reported adherence, but did not show significant viral load improvement over a 3-month period. PC4H is a feasible and acceptable digital health intervention for AYA living with HIV, but requires further study.

Digital technologies and adherence in respiratory diseases: the road ahead.

Outcomes for patients with chronic respiratory diseases remain poor despite the development of novel therapies. In part, this reflects the fact that adherence to therapy is low and clinicians lack accurate methods to assess this issue. Digital technologies hold promise to overcome these barriers to care. For example, algorithmic analysis of large amounts of information collected on health status and treatment use, along with other disease relevant information such as environmental data, can be used to help guide personalised interventions that may have a positive health impact, such as establishing habitual and correct inhaler use. Novel approaches to data analysis also offer the possibility of statistical algorithms that are better able to predict exacerbations, thereby creating opportunities for preventive interventions that may adapt therapy as disease activity changes. To realise these possibilities, digital approaches to disease management should be supported by strong evidence, have a solid infrastructure, be designed collaboratively as clinically effective and cost-effective systems, and reflect the needs of patients and healthcare providers. Regulatory standards for digital interventions and strategies to handle the large amounts of data generated are also needed. This review highlights the opportunities provided by digital technologies for managing patients with respiratory diseases.

Digital adherence technologies for the management of tuberculosis therapy: mapping the landscape and research priorities

Poor medication adherence may increase rates of loss to follow-up, disease relapse and drug resistance for individuals with active tuberculosis (TB). While TB programmes have historically used directly observed therapy...

Harnessing the Potential of Emerging Digital Health and Biological Sampling Technologies for Clinical Drug Development: Promise to Reality

Advances in emerging innovative technologies have led to optimistic outlooks on their transformative potential for healthcare and clinical trials.1 Given the increased attention, this white paper by the International Consortium for Innovation and Quality in Pharmaceutical Development (IQ) presents perspectives on pharmaceutical and biotechnology industry trends for innovative digital health, adherence, and outpatient sampling technologies. As stimulus for cross-company scientific dialog points to consider for adoption, implementation, and recommendations to broaden uptake are proposed.

Digital interventions to improve adherence to maintenance medication in asthma

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To determine the effectiveness of digital adherence interventions for improving adherence to maintenance treatments in asthma.

Use of Point of Care Testing (POCT) in measurement of hemoglobin

Point of care tests (POCT) are critical to success of public health programs like anemia control program which involve measurement of biomarkers; as they help in prompt decision making during first (and in many scenario the only) contact with the targeted beneficiary. There are many methods currently in use for point of care testing for hemoglobin estimation and include manual methods like Sahli’s method, Indirect cyanmethemoglobin method, WHO Hemoglobin Color Scale method; digital hemoglobinometers including the newer non-invasive devices. The current background paper reviewed available published literature regarding performance of different POCT methods for hemoglobin estimation. Available literature indicates that invasive digital hemoglobinometers have shown a reasonable performance for use as POCT in facility and community settings both for clinical diagnosis as well as surveys. Adequate training of front line workers for use of digital hemoglobinometers and adherence to standard operating procedures (SOPs) is essential to reduce errors/biases. Non-invasive digital hemoglobinometers seem to be promising new option for POCT which obviates the need for drawing blood sample (either by venous or capillary method) but further research and development is required before their use in programs.

New digital adherence devices could prevent millions of strokes from atrial fibrillation by the end of the next century

The effectiveness and safety of a pharmacologic intervention is highly dependent on patient’s capability to follow the recommended treatment regimen. Non-adherence to pharmacologic treatments is associated with worsening conditions including hospitalization and death. This is a significant burden to healthcare systems on a global scale with non-adherence rates being as high (or higher) as 50% in the first treatment year. The most common causes for non-adherence are forgetfulness, busy lifestyle or complexity and changes in therapeutic schedules. In conditions like atrial fibrillation (AFib) this leads to a drastic increase in event rates, e.g. strokes. Patients diagnosed with AFib are strongly recommended to receive anticoagulant treatments for stroke prevention. Treatments with Vitamin K antagonists or novel oral anticoagulants (NOACs) can dramatically lower the risk of ischemic strokes in the presence of AFib. Non-adherence can expose the patients to an increased stroke risk. This is especially true for NOACs, due to their short half-life. Patients have to take these medications once or twice daily for adequate stroke prevention, i.e., single non-use of the medication can already diminish or reset the anticoagulative effect. Adherence devices could help improve patient’s compliance by reminder or feedback function. They have shown to be successful in a number of clinical trails. Especially, newer devices that make use of digital technologies show promising results but are not used broadly in clinical practice. Here we provide evidence for our hypothesis that newly available adherence devices might increase adherence rates and thereby reduce the number of strokes in patients with AFib.

Rise of digital health and medical adherence technology raises concerns

Rise of digital health and medical adherence technology raises concerns