Systematic review of randomised controlled trials of strategies to promote adherence to tuberculosis treatment
BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7120.1403 (Published 29 November 1997) Cite this as: BMJ 1997;315:1403
- a South African Cochrane Centre, Medical Research Council, Box 19070, Tygerberg 7505, Cape Town, South Africa
- b International Health Division, Liverpool School of Tropical Medicine, University of Liverpool, Liverpool L3 5QA
- Correspondence to: Dr Volmink
- Accepted 2 October 1997
Abstract
Objective: To determine the effectiveness of strategies to promote adherence to treatment for tuberculosis.
Identification: Searches in Medline (1966 to August 1996), the Cochrane trials register (up to October 1996), and LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud) (1982 to September 1996); screening of references in articles on compliance and adherence; contact with experts in research on tuberculosis and adherence.
Inclusion criteria: Randomised or pseudorandomised controlled trials of interventions to promote adherence with curative or preventive treatment for tuberculosis, with at least one measure of adherence.
Main outcome measure: Relative risks and 95% confidence intervals for estimates of effect for categorical outcomes.
Results: Five trials met the inclusion criteria. The relative risk for tested reminder cards sent to patients who defaulted on treatment was 1.2 (95% confidence interval 1.1 to 1.4), for help given to patients by lay health workers 1.4 (1.1 to 1.8), for monetary incentives offered to patients 1.6 (1.3 to 2.0), for health education 1.2 (1.1 to 1.4), for a combination of a patient incentive and health education 2.4 (1.5 to 3.7) or 1.1 (1.0 to 1.2), and for intensive supervision of staff in tuberculosis clinics 1.2 (1.1 to 1.3). There were no completed trials of directly observed treatment. All of the interventions tested improved adherence. On current evidence it is unclear whether health education by itself leads to better adherence to treatment.
Conclusions: Reliable evidence is available to show some specific strategies improve adherence to tuberculosis treatment, and these should be adopted in health systems, depending on their appropriateness to practice circumstances. Further innovations require testing to help find specific approaches that will be useful in low income countries. Randomised controlled trials evaluating the independent effects of directly observed treatment are awaited.
Key messages
Despite adequate delivery systems, some patients with tuberculosis do not complete treatment
Six specific interventions have been tested in randomised trials to improve adherence, ranging from intensive staff supervision to monetary incentives for patients
This systematic review of randomised trials found that all of the strategies tested seemed to improve adherence
Independent effects of health education could not be assessed, and there are no trials yet available that test the effectiveness of directly observed treatment
Health providers should draw on what is known to be effective when designing strategies appropriate to local needs and circumstances
Further innovations, especially those that are feasible in developing countries, should be evaluated in randomised controlled trials before being introduced into routine practice.
Footnotes
- Accepted 2 October 1997