Material incentives and enablers in the management of tuberculosis.
Abstract
Background
Patient adherence to medications, particularly for conditions requiring
prolonged treatment such as tuberculosis, is frequently less than ideal,
and can result in poor treatment outcomes. Material incentives (given as
cash, vouchers and tokens), have been used to improve adherence.
Objectives
To assess the effects of material incentives in people undergoing
diagnostic testing, or receiving prophylactic or curative therapy, for
tuberculosis.
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; to 22 June 2011.
Selection criteria
Randomized controlled trials of material incentives in patients being
investigated for tuberculosis, or on treatment for latent or active
disease.
Data collection and analysis
At least two authors independently screened and selected studies,
extracted data, and assessed the risk of bias. The effects of
interventions are compared using risk ratios (RR), and presented with
95% confidence intervals (CI). The quality of the evidence was assessed
using GRADE.
Main results
We identified 11 eligible studies. 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). One additional trial recruited malnourished men receiving
active treatment for tuberculosis in Timor-Leste.
Material incentives may increase the return rate for reading of tuberculin skin test results compared to normal care (two trials, 1371 participants: RR 2.16, 95% CI 1.41 to 3.29, low quality evidence).
Similarly, incentives probably improve clinic re-attendance for initiation or continuation of antituberculosis prophylaxis (three trials, 595 participants: RR 1.58, 95% CI 1.27 to 1.96, moderate quality evidence), and may improve subsequent completion of prophylaxis in some settings (three trials, 869 participants: RR 1.79, 95% CI 0.70 to 4.58, low quality evidence).
We currently don't know if incentives can improve long-term adherence and completion of antituberculosis treatment for active disease. Only one trial has assessed this and 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 (one trial, 265 participants, RR 0.98, 95%CI 0.86 to 1.12, very low quality evidence).
Several trials have compared different forms or levels of incentive. These comparisons remain limited to single trials and robust conclusions cannot be made. In summary, cash incentives may be more effective than non-cash incentives (return for test results: one trial, 651 participants: RR 1.13, 95%CI 1.07 to 1.19, low quality evidence, adherence to tuberculosis prophylaxis: one trial, 141 participants: RR 1.26, 95%CI 1.02 to 1.56, low quality evidence) and higher amounts of cash may be more effective than lower amounts (return for test results: one trial, 404 participants: RR 1.08, 95%CI 1.01 to 1.16, low quality evidence).
Material incentives may also be more effective than motivational education at improving return for tuberculin skin test results (low quality evidence), but may be no more effective than peer counselling, or structured education at improving continuation or completion of prophylaxis (low quality evidence).
Authors' conclusions
There is limited evidence to support the use of material incentives to
improve return rates for tuberculosis diagnostic test results and
adherence to antituberculosis preventive therapy. The data are currently
limited to trials among predominantly male drug users, homeless, and
prisoner subpopulations in the USA, and therefore the results are not
easily generalised to the wider adult population, or to low- and
middle-income countries, where the tuberculosis burden is highest.
Further high-quality studies are needed to assess both the costs and effectiveness of incentives to improve adherence to long-term treatment of tuberculosis.
Plain Language Summary
Material incentives for improving patient adherence to tuberculosis
diagnosis, prophylaxis, and treatment:
Patients do not always follow the advice of health care providers if
being investigated or treated for tuberculosis. Material incentives
(such as cash, vouchers and tokens) may encourage them to return for the
results of tests or to take prescribed treatments. This review, which
analysed the results of 11 randomized controlled trials, concluded that
material incentives do increase the number of patients (in certain
marginalized subpopulations, mostly men) who return to the clinic to
receive their test results for the diagnosis of tuberculosis, and the
number of patients who go to the clinic to start treatment for
tuberculosis. There was no evidence to show that incentives increase the
number of patients who complete treatment for latent or active
tuberculosis.
Citation
Lutge, E. E.; Wiysonge, C. S.; Knight, S. E.; Volmink, J. Material incentives and enablers in the management of tuberculosis. Cochrane Database of Systematic Reviews (2012) (Issue 1) Art. No.: CD007952. [DOI: 10.1002/14651858.CD007952.pub2]
Links
Material incentives and enablers in the management of tuberculosis.