India accounts for 27% of the world’s tuberculosis cases, many of which are multidrug-resistant. RF MERL’s analysis of technology and treatment adherence can shape future treatment regimens for TB and beyond.
The Challenge
Tuberculosis (TB) is a major public health challenge around the world, but particularly in India, which suffers high rates of transmission and morbidity. The country has the highest global incidence rate of TB as well as the greatest number of individuals with multidrug-resistant TB, making the disease one of the top causes of death in India. The Government of India (GoI) has prioritized ending TB by 2025 and recently developed a National Strategic Plan that seeks to detect, treat, and prevent spread of TB cases while addressing the increased demand for care. The Plan places a high priority on strategies to increase patient adherence to lengthy treatment regimes in order to improve patient outcomes, reduce the number of cases that become drug-resistant, and, ultimately, to stem the tide of a rising TB infection rate.
The Opportunity
The Government of India dedicated resources to understanding the role of technology in enhancing patience care and treatment adherence as part of a National Strategic Plan through its Integrated Digital Adherence Technologies (IDAT) pilot, led by its Central TB Division (CTD) and evaluated by Rapid Feedback Monitoring, Evaluation, Research, and Learning (RF MERL), a USAID-funded consortium that is led by R4D and part of the Monitoring, Evaluation, Research, and Learning Innovations (MERLIN) Program.
The IDAT pilot assessed the feasibility and utility of three different adherence technologies: the directly observed treatment, short-course (99DOTS) medication packaging and calling system; medication event reminder monitor (MERM) boxes; and video-observed therapy (VOT). Specifically, the pilot assessed adherence technologies across urban and rural areas in Gujarat, Karnataka, and Haryana. RF MERL, in partnership with USAID/India, CTD and World Health Partners (WHP), used proven evaluation methods and rapid feedback loops to foster learning and adaptation by informing future iterations of the pilot. Specifically, RF MERL developed research questions on technology assignment; patient use; and improvements to patient support through technologies and patient counseling.
RF MERL conducted a rapid feedback assessment using a mixed-methods analysis, which evaluated the feasibility and utility of the three adherence technologies.
The findings and recommendations from the pilot are already being used for improved technology assignment and updated counseling protocols as CTD moves into its next phase for IDAT across Gujarat and Jharkhand.
Our Work/Progress/Results
RF MERL analyzed two rounds of national patient-level quantitative data and conducted focus groups and key informant interviews with patients, providers, and healthcare workers, in coordination with World Health Partners (WHP), Karnataka Health Promotion Trust (KHPT), and ZMQ Development. Through a series of reports and Learning Checks (convenings of key stakeholders to pause and reflect on the findings from the research activities and to discuss the implications for future research/programming), findings from these analyses were integrated over the past year into TB programming and treatment regimens. The RF MERL engagement identified several important key takeaways for consideration:
- Technology assignment varied by patients’ state, sector, age, gender, and educational level, with most patients assigned 99DOTS
- Patients who were assigned technologies thought the assignment showed that the government cared about their treatment regime; however, they recognized technology is not a panacea
- Technologies offer a way to estimate patient adherence and save healthworker time, but challenges with recording doses, cellular signal, and supply chains mean they are not a replacement for healthworker engagement
- Patients in the private sector were less likely to be assigned a technology, but had higher engagement with the technologies than patients in the public sector
- Patient counseling was identified as the next priority area for ensuring continuity of care, as establishing an open relationships with patients can mitigate patient confusion and improve engagement
- Women, marginalized patients, and those with less technology familiarity experienced the technologies differently and faced more barriers than other patients
IDAT findings revealed that it would be feasible to scale multiple technologies to suit the diverse patient populations of the pilot geographies. However, patient characteristics must be taken into consideration to improve technology engagement and, ultimately, adherence. The next phase of the IDAT pilot will include work to improve patient and healthcare worker experience with the technologies through tailored support and counseling. This “Enhanced Care” protocol draws on lessons from the RF MERL engagement with the goal of improving patient adherence for TB treatment regimens.
