Implementation outcomes of tuberculosis digital adherence technologies: a scoping review using the RE-AIM framework

Abstract

AbstractIntroductionGlobally, tuberculosis (TB) remains one of the leading infectious causes of death, with 1.3 million deaths. Digital adherence technologies (DATs) have the potential to provide person-centred care and improve outcomes. Using the RE-AIM framework, we conducted a scoping review of DAT implementations for TB treatment.MethodsWe searched eight databases for papers published between January 2000 and April 2023, using keywords for ‘tuberculosis’ and ‘digital adherence technology’. Articles meeting prespecified inclusion criteria and containing data on RE-AIM domains were included (PROSPERO-CRD42022326968). We defined ‘reach’ as comprising cellphone ownership and engagement by people with TB (PWTB) with DATs, ‘adoption’ as engagement by healthcare providers with DAT programs, ‘implementation’ as the fidelity of the DAT program implemented, and ‘maintenance’ as longer-term uptake of DATs.ResultsOf 10,313 records, 105 contributed to the synthesis. DATs included SMS, phone, 99DOTS, video-supported therapy and pillboxes. For ‘reach’, across various settings, cellphone access varied from 50-100% and 2-31% of PWTB were excluded from accessing DATs due to technology challenges. 36-100% of PWTB agreed to use a DAT. The weighted mean of DAT engagement over dose-days was 81% for SMS, 85% for phone, 61% for 99DOTS, 87% for pillbox and 82% for VST. Concerning ‘implementation’, the fidelity of DAT implementations was affected by technological issues such as cellphone coverage, DAT malfunction and provider-facing issues; including failure to initiate intensified patient management following low DAT engagement. Findings related to RE-AIM dimensions of ‘adoption’ and ‘maintenance’ were limited.ConclusionOur findings suggest that the ‘reach’ of DATs may be limited by a cascade of barriers, including limitations in cellphone accessibility and suboptimal sustained DAT engagement by PWTB. Video and pillbox DATs have higher levels of engagement. Implementation challenges included technological and provider-facing issues. Improving implementation outcomes may be important for TB DATs to achieve broader public health impact.