Incentives and enablers to improve adherence in tuberculosis

Elizabeth E Lutge, Charles Shey Wiysonge, Stephen E Knight, David Sinclair, Jimmy Volmink, Elizabeth E Lutge, Charles Shey Wiysonge, Stephen E Knight, David Sinclair, Jimmy Volmink

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 programmesOnly 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 recently released prisoners (373 participants), or another trial assessing material incentives offered by parents to teenagers (388 participants). Single once-only incentivesHowever in specific populations, such as recently released prisoners, drug users, and the homeless, trials show that material incentives probably do improve one-off clinic re-attendance for initiation or continuation of anti-TB prophylaxis (RR 1.58, 95% CI 1.27 to 1.96; three trials, 595 participants; moderate quality evidence), and may increase the return rate for reading of tuberculin skin test results (RR 2.16, 95% CI 1.41 to 3.29; two trials, 1371 participants; low quality evidence). Comparison of different types of incentivesSingle trials in specific sub-populations suggest that an immediate cash incentive may be more effective than delaying the incentive until completion of treatment (RR 1.11, 95% CI 0.98 to 1.24; one trial, 300 participants; low quality evidence), cash incentives may be more effective than non-cash incentives (completion of TB prophylaxis: RR 1.26, 95% CI 1.02 to 1.56; one trial, 141 participants; low quality evidence; return for skin test reading: RR 1.13, 95% CI 1.07 to 1.19; one trial, 652 participants; low quality evidence); and higher cash incentives may be more effective than lower cash incentives (RR 1.08, 95% CI 1.01 to 1.16; one trial, 404 participants; low quality evidence).

Authors' conclusions: Material incentives and enablers may have some positive short term effects on clinic attendance, particularly for marginal populations such as drug users, recently released prisoners, and the homeless, but there is currently insufficient evidence to know if they can improve long term adherence to TB treatment.

Conflict of interest statement

EL was the principal investigator in the new study included in the current review update (Lutge 2013). However, two review authors who were not involved with this trial (DS and CSW) independently extracted and verified data. Two Cochrane Editors provided oversight.

Figures

1
1
PRISMA diagram showing the search and selection of studies
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1. Analysis
1.1. Analysis
Comparison 1 Incentive versus routine care, Outcome 1 Treatment success (completion or cure).
1.2. Analysis
1.2. Analysis
Comparison 1 Incentive versus routine care, Outcome 2 Completion of TB prophylaxis.
1.3. Analysis
1.3. Analysis
Comparison 1 Incentive versus routine care, Outcome 3 Clinic visit to start or continue TB prophylaxis.
1.4. Analysis
1.4. Analysis
Comparison 1 Incentive versus routine care, Outcome 4 Return for tuberculin skin test results.
2.1. Analysis
2.1. Analysis
Comparison 2 Immediate versus deferred incentive, Outcome 1 Completion of TB prophylaxis.
3.1. Analysis
3.1. Analysis
Comparison 3 Cash incentive versus non‐cash incentive, Outcome 1 Completion of TB prophylaxis.
3.2. Analysis
3.2. Analysis
Comparison 3 Cash incentive versus non‐cash incentive, Outcome 2 Return for tuberculin skin test reading.
4.1. Analysis
4.1. Analysis
Comparison 4 Incentives versus any other intervention, Outcome 1 Completion of TB prophylaxis.
4.2. Analysis
4.2. Analysis
Comparison 4 Incentives versus any other intervention, Outcome 2 Clinic visit to start or continue TB prophylaxis.
4.3. Analysis
4.3. Analysis
Comparison 4 Incentives versus any other intervention, Outcome 3 Return for tuberculin skin testing.
5.1. Analysis
5.1. Analysis
Comparison 5 Different values of cash incentive, Outcome 1 Return for tuberculin skin test reading.

References

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Malotte 1999 {published data only}
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Source: PubMed

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