Skip to main page content
Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2015 Sep 3;2015(9):CD007952.
doi: 10.1002/14651858.CD007952.pub3.

Incentives and Enablers to Improve Adherence in Tuberculosis

Affiliations
Free PMC article
Review

Incentives and Enablers to Improve Adherence in Tuberculosis

Elizabeth E Lutge et al. Cochrane Database Syst Rev. .
Free PMC article

Abstract

Background: Patient adherence to medications, particularly for conditions requiring prolonged treatment such as tuberculosis (TB), is frequently less than ideal and can result in poor treatment outcomes. Material incentives to reward good behaviour and enablers to remove economic barriers to accessing care are sometimes given in the form of cash, vouchers, or food to improve adherence.

Objectives: To evaluate the effects of material incentives and enablers in patients undergoing diagnostic testing, or receiving prophylactic or curative therapy, for TB.

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 up to 5 June 2015.

Selection criteria: Randomized controlled trials of material incentives in patients being investigated for TB, or on treatment for latent or active TB.

Data collection and analysis: At least two review authors independently screened and selected studies, extracted data, and assessed the risk of bias in the included trials. We compared the effects of interventions using risk ratios (RR), and presented RRs with 95% confidence intervals (CI). The quality of the evidence was assessed using GRADE.

Main results: We identified 12 eligible trials. 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). The remaining two trials, in general adult populations, were conducted in Timor-Leste and South Africa. Sustained incentive programmesOnly two trials have assessed whether material incentives and enablers can improve long-term adherence and completion of treatment for active TB, and neither demonstrated a clear benefit (RR 1.04, 95% CI 0.97 to 1.14; two trials, 4356 participants; low quality evidence). In one trial, 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, whilst in the other trial, nurses distributing the vouchers chose to "ration" their distribution among eligible patients, giving only to those whom they felt were most deprived.Three trials assessed the effects of material incentives and enablers on completion of TB prophylaxis with mixed results (low quality evidence). A large effect was seen with regular cash incentives given to drug users at each clinic visit in a setting with extremely low treatment completion in the control group (treatment completion 52.8% intervention versus 3.6% control; RR 14.53, 95% CI 3.64 to 57.98; one trial, 108 participants), but no effects were seen in one trial assessing a cash incentive for recently released prisoners (373 participants), or another trial assessing material incentives offered by parents to teenagers (388 participants). Single once-only incentivesHowever in specific populations, such as recently released prisoners, drug users, and the homeless, trials show that material incentives probably do improve one-off clinic re-attendance for initiation or continuation of anti-TB prophylaxis (RR 1.58, 95% CI 1.27 to 1.96; three trials, 595 participants; moderate quality evidence), and may increase the return rate for reading of tuberculin skin test results (RR 2.16, 95% CI 1.41 to 3.29; two trials, 1371 participants; low quality evidence). Comparison of different types of incentivesSingle trials in specific sub-populations suggest that an immediate cash incentive may be more effective than delaying the incentive until completion of treatment (RR 1.11, 95% CI 0.98 to 1.24; one trial, 300 participants; low quality evidence), cash incentives may be more effective than non-cash incentives (completion of TB prophylaxis: RR 1.26, 95% CI 1.02 to 1.56; one trial, 141 participants; low quality evidence; return for skin test reading: RR 1.13, 95% CI 1.07 to 1.19; one trial, 652 participants; low quality evidence); and higher cash incentives may be more effective than lower cash incentives (RR 1.08, 95% CI 1.01 to 1.16; one trial, 404 participants; low quality evidence).

Authors' conclusions: Material incentives and enablers may have some positive short term effects on clinic attendance, particularly for marginal populations such as drug users, recently released prisoners, and the homeless, but there is currently insufficient evidence to know if they can improve long term adherence to TB treatment.

Conflict of interest statement

EL was the principal investigator in the new study included in the current review update (Lutge 2013). However, two review authors who were not involved with this trial (DS and CSW) independently extracted and verified data. Two Cochrane Editors provided oversight.

Figures

Figure 1
Figure 1
PRISMA diagram showing the search and selection of studies
Figure 2
Figure 2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figure 3
Figure 3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Analysis 1.1
Analysis 1.1
Comparison 1 Incentive versus routine care, Outcome 1 Treatment success (completion or cure).
Analysis 1.2
Analysis 1.2
Comparison 1 Incentive versus routine care, Outcome 2 Completion of TB prophylaxis.
Analysis 1.3
Analysis 1.3
Comparison 1 Incentive versus routine care, Outcome 3 Clinic visit to start or continue TB prophylaxis.
Analysis 1.4
Analysis 1.4
Comparison 1 Incentive versus routine care, Outcome 4 Return for tuberculin skin test results.
Analysis 2.1
Analysis 2.1
Comparison 2 Immediate versus deferred incentive, Outcome 1 Completion of TB prophylaxis.
Analysis 3.1
Analysis 3.1
Comparison 3 Cash incentive versus non‐cash incentive, Outcome 1 Completion of TB prophylaxis.
Analysis 3.2
Analysis 3.2
Comparison 3 Cash incentive versus non‐cash incentive, Outcome 2 Return for tuberculin skin test reading.
Analysis 4.1
Analysis 4.1
Comparison 4 Incentives versus any other intervention, Outcome 1 Completion of TB prophylaxis.
Analysis 4.2
Analysis 4.2
Comparison 4 Incentives versus any other intervention, Outcome 2 Clinic visit to start or continue TB prophylaxis.
Analysis 4.3
Analysis 4.3
Comparison 4 Incentives versus any other intervention, Outcome 3 Return for tuberculin skin testing.
Analysis 5.1
Analysis 5.1
Comparison 5 Different values of cash incentive, Outcome 1 Return for tuberculin skin test reading.

Update of

Similar articles

See all similar articles

Cited by 22 articles

See all "Cited by" articles

References

References to studies included in this review

    1. Chaisson RE, Barnes GL, Hackman J, Watkinson L, Kimbrough L, Metha S, et al. A randomised, controlled trial of interventions to improve adherence to isoniazid therapy to prevent tuberculosis in injection drug users. American Journal of Medicine 2001;110(8):610‐15. - PubMed
    1. Lutge E, Lewin S, Volmink J. Economic support to improve tuberculosis treatment outcomes in South Africa: a qualitative process evaluation of a cluster randomized controlled trial. Trials 2014;15:236. - PMC - PubMed
    2. Lutge E, Lewin S, Volmink J, Friedman I, Lombard C. Economic support to improve tuberculosis treatment outcomes in South Africa: a pragmatic cluster randomised controlled trial. Trials 2013;14:154. - PMC - PubMed
    1. Malotte CK, Rhodes F, Mais KE. Tuberculosis screening and compliance with return for skin test reading among active drug users. American Journal of Public Health 1998;88(5):792‐6. - PMC - PubMed
    1. Malotte CK, Hollingshead JR, Rhodes F. Monetary versus nonmonetary incentives for TB skin test reading among drug users. American Journal of Preventive Medicine 1999;16(3):182‐8. - PubMed
    1. Malotte CK, Hollingshead JR, Larro M. Incentives vs outreach workers for latent tuberculosis treatment in drug users. American Journal of Preventive Medicine 2001;20(2):103‐7. - PubMed

References to studies excluded from this review

    1. Cantalice Filho JP. Food baskets given to tuberculosis patients at a primary health care clinic in the city of Duque de Caxias, Brazil: effect on treatment outcomes. Jornal Brasileiro de Pneumologia 2009;35(10):992‐7. - PubMed
    1. Cheng TL, Ottolini MC, Baumhaft K, Brasseux C, Wolf MD, Scheidt PC. Strategies to increase adherence with tuberculosis test reading in a high‐risk population. Pediatrics 1997;100(2 Pt 1):210‐3. - PubMed
    1. Chua AP, Lim LK, Ng H, Chee CB, Wang YT. Outcome of a grocery voucher incentive scheme for low‐income tuberculosis patients on directly observed therapy in Singapore. Singapore Medical Journal 2015;56(5):274‐9. - PMC - PubMed
    1. FitzGerald JM, Patrick DM, Strathdee S, Rekart M, Elwood RK, Schecter MT, et al. Use of incentives to increase compliance for TB screening in a population of intravenous drug users. International Journal of Tuberculosis and Lung Diseases 1999;3(2):153‐5. - PubMed
    1. Gärden B, Samarina A, Stavchanskaya I, Alsterlund R, Övregaard A, Taganova O, et al. Food incentives improve adherence to tuberculosis drug treatment among homeless patients in Russia. Scandinavian Journal of Caring Sciences 2013;27(1):117‐22. - PubMed

Additional references

    1. Balshem B, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Broze J, et al. GRADE guidelines: 3. Rating the quality of evidence. Journal of Clinical Epidemiology 2011;64(4):401‐6. - PubMed
    1. Beith A, Eichler R, Weil D. Performance‐Based Incentives for Health: A Way to Improve Tuberculosis Detection and Treatment Completion?. Center for Global Development Working Paper 1222007.
    1. Centers for Disease Control and Prevention. Latent Tuberculosis Infection: A Guide for Primary Health Care Providers. Atlanta, Georgia: CDC, 2010.
    1. Garner P, Smith H, Munro S, Volmink J. Promoting adherence to tuberculosis treatment. Bulletin of the World Health Organization 2007;85(5):404‐6. - PMC - PubMed
    1. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck‐Ytter Y, Alonso‐Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924‐6. - PMC - PubMed

References to other published versions of this review

    1. Lutge EE, Wiysonge CS, Knight SE, Volmink J. Material incentives and enablers in the management of tuberculosis. Cochrane Database of Systematic Reviews 2012, Issue 1. [DOI: 10.1002/14651858.CD007952.pub2] - DOI - PubMed

MeSH terms

LinkOut - more resources

Feedback