Strategies to Promote Adherence to Treatment by Pulmonary Tuberculosis Patients: A systematic review

BACKGROUND:

Successful tuberculosis control depends upon effective treatment of patients which requires adherence throughout the full course of medical treatment. Poor adherence to treatment is a major obstacle in the global fight against tuberculosis. Therefore, interventions that promote adherence to the tuberculosis treatment regimen should be implemented.

OBJECTIVE:

To review and synthesise the best available research evidence that investigates the effectiveness of strategies to promote adherence to treatment by patients with pulmonary tuberculosis.

INCLUSION CRITERIA:

TYPES OF PARTICIPANTS:

This review considered all studies that included adults aged ≥ 15 years diagnosed with smear positive and smear negative pulmonary tuberculosis (regardless of HIV infection) in community settings who had never received anti-tuberculosis drugs, or had taken them for less than one month.

TYPES OF INTERVENTION:

Intervention included strategies to promote adherence to tuberculosis treatment by patients with pulmonary tuberculosis.

TYPES OF OUTCOME:

Outcomes included measures for treatment completion rate, cure rate, and success rate.

TYPES OF STUDIES:

The review primarily considered any randomised controlled trials that explored different strategies to promote adherence to tuberculosis treatment of patients with pulmonary tuberculosis but also included quasi-experimental studies.

SEARCH STRATEGY:

The search sought to find published and unpublished studies. The time period of the search covered articles published from 1990 to 2010 in English and Thai language. The database searches included: CINAHL, EMBASE, Cochrane Library, PubMed, Science Direct, Current Content Connect, Thai Nursing Research Database, Thai thesis database, Digital Library of Thailand Research Fund, Research of National Research Council of Thailand, and Database of Office of Higher Education Commission. Studies were additionally identified from reference lists of all studies retrieved.

METHODOLOGICAL QUALITY:

Studies selected for retrieval were assessed by two independent reviewers for methodological quality using a standardised critical appraisal tool from the Joanna Briggs Institute.

DATA COLLECTION:

Data extraction was performed using a standardised data extraction form from the Joanna Briggs Institute.

DATA SYNTHESIS:

The quantitative study results were pooled in statistical meta-analysis using the Review Manager software (RevMan 5.0) and summarised in narrative form where statistical pooling was not appropriate or possible.

RESULTS:

This systematic review included ten randomised controlled trials and eight quasi-experimental studies that report on the effectiveness of a number of specific interventions to improve adherence to tuberculosis treatment among newly diagnosed pulmonary tuberculosis patients. These interventions included Directly Observed Treatment coupled with alternative patient supervision options, case management with Directly Observed Treatment, Short-course, the intensive triad-model program, and an intervention package consisting of improving patients’ counselling and communication, decentralisation of treatment, patient choice of Directly Observed Treatment supporter, and reinforcement of supervision activities.

CONCLUSION:

The interventions that had the best outcomes for treatment adherence among newly diagnosed pulmonary tuberculosis patients were Directly Observed Treatment and Directly Observed Treatment, Short-course combined with case management, improving counselling and communication and decentralisation of treatment. These interventions should be implemented by health care providers and tailored to local contexts and circumstances, where appropriate.