Leveraging mHealth intervention to ensure initiation of treatment for tuberculosis
The George Institute for Global Health, New Delhi, India
V R Keshri
The George Institute for Global Health, New Delhi
|How to cite this article:|
Keshri V R. Leveraging mHealth intervention to ensure initiation of treatment for tuberculosis.J Postgrad Med 2021;67:194-195
|How to cite this URL:|
Keshri V R. Leveraging mHealth intervention to ensure initiation of treatment for tuberculosis. J Postgrad Med [serial online] 2021 [cited 2022 May 21 ];67:194-195
Available from: https://www.jpgmonline.com/text.asp?2021/67/4/194/331273
Tuberculosis (TB) is one of the 10 leading causes of death globally and the leading cause of death from a single infectious disease. In 2019, 10 million new cases and 1.2 million deaths were estimated from TB worldwide. India contributes to 26% of the global burden of TB cases. In 2019, 2.6 million new cases and 436,000 deaths were estimated to be due to TB in India. The year 2020 was certainly a turning point in the history of infectious diseases. The onset of the ongoing COVID-19 pandemic is causing devastating effects worldwide. It has significantly disrupted health systems and affected the availability and accessibility of routine health care. The challenges for accessing services are even more intricate for TB as it requires long-term treatment.
In 2020, India renamed its national TB control program as National TB Elimination program with a target to eliminate TB from India by 2025. Early diagnosis and adequate treatment are the most critical evidence-based strategy to control and eliminate TB. Incidentally, the extent of failure on treatment initiation and completion is significantly high. After the onset of COVID pandemic, containment strategies have resulted in significant limitations in movement and interpersonal interaction. As a result, the number of new patients registered for TB treatment in India has significantly gone down during the ongoing pandemic. The use of technology for the delivery of health care emerged as an important alternative, and the mobile phone has emerged as the most used tool. mHealth, which means the use of mobile technologies for helping achieve health objectives, has played a significant role in ensuring a continuum of care.
In this issue of the journal, Majella et al have reported their findings of a randomized controlled trial (RCT) conducted to assess the use of mobile voice call follow-up on treatment initiation among TB patients. These patients were diagnosed at tertiary hospitals and referred to the peripheral public health institution for treatment. Approximately 25% of TB patients in India are diagnosed at tertiary hospitals and their treatment gets initiated at peripheral public health institutions. Pre-treatment loss to follow-up (PTLFU) among this group of patients has been identified to be an important bottleneck in TB control. The pathway for initiation of treatment for such patients is long and complex. Patients are required to meet many health personnel carrying a paper-based referral slip and visit a health facility to initiate treatment. In the year 2012, the Government of India has launched a system called NIKSHAY to keep a track of the TB patients across the country. This e-health initiative aims to track referred patients by notifying the concerned TB program officer and health provider at the chosen treatment center. It also aims to reduce PTLFU, but the entire process depends on tracking the patient by the health worker.
Currently there are approximately 1.1 billion mobile phone connections in India. The mobile phone has significantly changed the way health messages and reminders are delivered to people. In TB many mHealth interventions are successfully implemented to enhance compliance to treatment and reduce loss to follow-up during treatment. However, evidence on the use of mobile voice call for reminding referred patients to ensure initiation of treatment is limited.
In this context, the findings of this study by Majella et al is an important evidence. Results are quite encouraging as shown by an absolute risk difference of 9% between intervention and control and the estimate that at least one PTLFU can be prevented by mobile voice call to 11 referred patients. On multivariate analysis, the participants in the intervention arm were found to have a 0.5 times lower risk of PTLFU. Among the control group, lack of understanding about TB and where to go for initiation of treatment was the most common reason for PTLFU. Other common reasons for non-initiation of treatment were hospitalization elsewhere, non-availability of appropriate drug boxes, loss of referral slip, and inability to travel to the assigned health center. An important bottleneck for the proposed intervention was the lack of access to mobile phones for around 20% of the patients and the inability to telephonically connect to around 5% of patients. A study from Cambodia reports similar findings, but it was based on two successive cohorts. In the Indian context, the findings of this paper are critical for setting the tone for generating more evidence on programmatic implementation. Going forward, this intervention has the potential to be considered for inclusion among one of the strategies of the National TB Elimination Program.
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