Acceptability and feasibility of digital adherence technologies for tuberculosis treatment supervision: A meta-analysis of implementation feedback

IntroductionDigital adherence technologies (DATs) have emerged as an alternative to directly observed therapy (DOT) for supervisions of tuberculosis (TB) treatment. We conducted a meta-analysis of implementation feedback obtained from people with TB and health care workers (HCWs) involved in TB REACH Wave 6-funded DAT evaluation projects. MethodsProjects administered standardized post-implementation surveys based on the Capability, Opportunity, Motivation, Behavior (COM-B) model to people with TB and their health care workers. The surveys included questions on demographics and technology use, Likert scale questions to assess capability, opportunity, and motivation to use DAT and open-ended feedback. We summarized demographic and technology use data descriptively, generated pooled estimates of responses to Likert scale questions within each COM-B category for people with TB and health care workers using random effects models, and performed qualitative analysis of open-ended feedback using a modified framework analysis approach. ResultsThe analysis included surveys administered to 1290 people with TB and 90 HCWs across 6 TB REACH-funded projects. People with TB and HCWs had an overall positive impression of DATs with pooled estimates between 4{middle dot}0 to 4{middle dot}8 out of 5 across COM-B categories. However, 44% of people with TB reported taking TB medications without reporting dosing via DATs and 23% reported missing a dose of medication. Common reasons included problems with electricity, network coverage, and technical issues with the DAT platform. DATs were overall perceived to reduce visits to clinics, decrease cost, increase social support, and decrease workload of HCWs. ConclusionDATs were acceptable in a wide variety of settings. However, there were challenges related to the feasibility of using current DAT platforms. Implementation efforts should concentrate on ensuring access, anticipating, and addressing technical challenges, and minimizing additional cost to people with TB. Author SummaryDigital adherence technologies (DATs) are increasingly being implemented as an alternative to traditional directly observed therapy (DOT) for TB treatment. However, to date there are limited data on their feasibility and acceptability among both persons on treatment and health care workers, resulting in only a conditional recommendation for their use in TB treatment by the World Health Organization in their 2017 Guidelines for treatment of drug-susceptible tuberculosis and patient care. Our study provides information on the feasibility and acceptability of implementing and using different DATs in a variety of settings and target populations for TB treatment adherence. The use of a similar survey across multiple sites helps provides a common understanding of facilitators and barriers on the use of DATs as global and national TB programs consider the expansion of the use of these tools. Our evidence demonstrates a high acceptability of DATs and supports further implementation of DATs as a component of TB treatment support. However, implementation efforts need to address issues concerning access to these tools, the technical challenges that are associated with the platforms, while minimizing additional burdens and costs to people with TB.