International Journal of Infectious Diseases 65 (2017) 85–89

Contents lists available at ScienceDirect

International Journal of Infectious Diseases

journal homepage: www.elsevier.com/locate/ijid

Video Directly Observed Therapy to support adherence with treatment

for tuberculosis in Vietnam: A prospective cohort study
Thu Anh Nguyena , Minh Tam Phama , Thi Loi Nguyena , Viet Nhung Nguyenb,c ,
Duc Cuong Phama , Binh Hoa Nguyenc,d, Greg James Foxa,e,*
a
Woolcock Institute of Medical Research, Glebe, NSW 2037, Australia
b
National Lung Hospital, Ba Dinh, Hanoi, Vietnam
c
Hanoi Medical University, Hanoi, Vietnam
d
Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France
e
Sydney Medical School, University of Sydney, NSW 2006, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Background: Ensuring patients fully adhere to their treatment is a major challenge for TB control
Received 13 September 2017 programmes in resource-limited settings. This study was conducted three outpatient tuberculosis clinics
Received in revised form 27 September 2017 in Hanoi, Vietnam. We aimed to evaluate the feasibility of using asynchronous Video Directly Observed
Accepted 29 September 2017
Therapy (VDOT) to support treatment adherence among patients with bacteriologically confirmed
Corresponding Editor: Eskild Petersen, Aar-
hus, Denmark
pulmonary tuberculosis.
Methods: In this cohort study, consecutive adult patients with bacteriologically confirmed pulmonary TB
were invited to enroll in a programme of VDOT. Patients were trained to use a smartphone to record
Keywords:
Tuberculosis
themselves taking treatment for TB. Videos were uploaded to an online server and reviewed daily by
Adherence support study staff for at least two months. Adherence was evaluated based upon monthly pill count.
Video Results: Between November 2016 and January 2017, 40 of 78 eligible participants (51.3%) agreed to
Technology commence VDOT. Among participating patients, 27 (71.1%) of patients took all required doses. A median
Treatment of 88.4% (interquartile range 75.8%-93.7%) of doses were correctly recorded and uploaded. Participants
rated the VDOT interface highly, despite facing some initial technical difficulties.
Conclusion: VDOT was feasible and resulted in high rates of treatment adherence in a resource-limited
setting.
© 2017 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Background (Kaona et al., 2004; Adane et al., 2013). The consequences of

incomplete adherence are well-documented, and include an
Tuberculosis (TB) affects 10.4 million people each year, the vast increased risk of treatment failure, acquired drug resistance and
majority of whom live in resource-limited settings (World Health continuing propagation of infection (Weaver et al., 2015; Karumbi
Organization, 2016). Optimal regimens for drug susceptible and Garner, 2015; Suwankeeree and Picheansathian, 2014). A range
tuberculosis require six months of daily antibiotics (World Health of programmatic strategies have been proposed to strengthen
Organization, 2017; Johnston et al., 2017). However, ensuring adherence (Story et al., 2016; Wald et al., 2015; Lutge et al., 2015).
patients fully adhere to their treatment is a perennial challenge for However, in many resource-limited settings, intensive adherence
TB control programmes, particularly during the final months support strategies such as Direct Observation of Therapy (DOT) are
of treatment when patients’ symptoms have largely resolved often infeasible due to limitations in the health workforce, and
barriers to patients accessing care. New scaleable methods to
improve adherence, and hence treatment outcomes, will be
* Corresponding author at: Rm 5216, Level 2 Medical Foundation Building, 92-94 essential if the global ambition of TB elimination is to be realised
Parramatta Road, The University of Sydney, NSW 2006, Australia. (Uplekar et al., 2015).
E-mail addresses: [email protected] (T.A. Nguyen), Advances in digital communications technology hold consider-
[email protected] (M.T. Pham), [email protected]
(T.L. Nguyen), [email protected] (V.N. Nguyen),
able promise to transform adherence support. Recognising this
[email protected] (D.C. Pham), [email protected] potential, the WHO Digital Health for the End TB Strategy calls for
(B.H. Nguyen), [email protected] (G.J. Fox). evidence-based approaches to underpin the scale-up of new

https://doi.org/10.1016/j.ijid.2017.09.029
1201-9712/© 2017 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
86 T.A. Nguyen et al. / International Journal of Infectious Diseases 65 (2017) 85–89

technologies (World Health Organization, 2015). However, there is Study procedures

limited evidence to demonstrate the feasibility of digital strategies
to support adherence in resource-limited settings (Story et al., Staff working at participating outpatient facilities invited
2016; Liu et al., 2015). consecutive patients attending the clinic to receive scheduled
Video Directly Observed Therapy (VDOT) is a method of treatment for TB to enroll in the study. Consenting participants
adherence monitoring that involves patients transmitting digital were asked for information about their demographics, socioeco-
images of their ingestion of treatment to a central location for nomic factors, medical history and mobile phone use. Additional
review. Two broad approaches have been applied. ‘Synchronous’ information about their diagnosis and treatment regimen was
VDOT involves the review of transmitted images in real time by collected from the patient’s medical file.
health care workers. In contrast, ‘asynchronous’ VDOT allows VDOT was performed using the SureAdhere platform (Sure-
videos to be recorded, uploaded and reviewed at a later time – Adhere, San Diego, CA), an asynchronous smartphone application
providing greater flexibility to patients and clinical staff. VDOT (‘App’) that allowed videos to be recorded, uploaded and viewed
has been shown to be feasible and acceptable to patients in some at a later time by study staff (Garfein et al., 2015). The platform
high-income settings (Story et al., 2016; Mirsaeidi et al., 2015; could be used either with an Android or iOS smartphone. Videos
Garfein et al., 2015). However, these studies may not be could be transmitted over a 3G or 4G mobile network, or through
applicable to resource-limited settings, where the burden of a WiFi connection. Continuous connectivity was not necessarily,
TB is the highest. We aimed to evaluate the feasibility and as the app stored videos and repeatedly attempted to transmit
acceptability of asynchronous VDOT for patients with bacterio- them, until a network was detected and transmission succeeded.
logically confirmed pulmonary TB in Vietnam, a high prevalence Study participants who already owned a smart phone could use
country for TB. their own phone to participate in the study. Low-cost smart-
phones with 3G connectivity were loaned to patients who did not
Methods own a smartphone. Cellular data charges were paid for by the
study.
Study setting At enrolment, consenting study participants received a
30 minute training session about how to use the smartphone
Vietnam is a low middle-income country in Southeast Asia with and the VDOT app. This included practice recording and uploading
a TB incidence of 137 (110-166) per 100,000 population in 2015, a video and provision of written instructions. Additional face-to-
which remains persistently high despite more than 90% of patients face training was provided by the study staff to any patients
reporting treatment completion over the past two decades (World reporting technical difficulties during the intervention period.
Health Organization, 2016). Tuberculosis control is delivered by a Adherence monitoring using VDOT was to be carried out for at
centrally administered National TB Program (NTP). Treatment is least 60 days. Each day, at a time nominated by the study
routinely overseen by nominated household members, ‘Family participant, a Short Messaging Service (SMS) message was
DOT supporters’ or community volunteers. Treatment is not automatically generated to remind the participant to upload a
directly observed by health workers, in accordance with national video. If the video had not been received after one hour, a second
guidelines. Medications are dispensed free-of-charge, most SMS was sent. If a video upload was missed, despite the SMS, study
commonly once each week by health workers at district clinics, staff called the patient to provide support, and remind them to take
or commune health post. Clinical review occurs at district clinics treatment.
second monthly throughout treatment. Videos were automatically uploaded via the mobile network,
The country has among the highest rates of mobile phone including date and time of recording, and viewed by the study staff
ownership in the world (International Telecommunication Union, on a secure website to verify adherence. Patients reported side
2017), with 131 mobile phone subscriptions per 100 people effects verbally, by describing them during the daily video
(International Telecommunication Union, 2017). One third of the recording. Adherence was recorded by study staff as adequate if
adult population owns a smartphone, with use increasing annually a participant held up all required tablets, placed them in their
(Poushter, 2016). mouth and swallowed. The video and audio quality were reported.
At the end of each month, study staff interviewed study
Study design participants during a scheduled clinic visit. Follow-up was
completed when patients returned for a scheduled visit at the
We conducted a prospective cohort study in three outpatient end of two months of follow-up. Treatment adherence was
facilities conducted within tuberculosis outpatient facilities in assessed based upon pill count of remaining tablets. A question-
Hanoi, Vietnam. naire evaluating difficulties with using the smartphone, or the app,
Patients with bacteriologically confirmed pulmonary tubercu- was completed at each visit. Adverse events were managed
losis were recruited from the outpatient departments at three routinely by the staff of the NTP.
clinics of the National Tuberculosis Program (NTP) in Hanoi, At each visit, participants were asked to provide feedback about
Vietnam. Patients were eligible to enroll in the study if they were at the VDOT system. At the end of follow-up, participants were asked
least 15 years of age, receiving a regimen containing only oral to evaluate their experience, and rate the ease of use the
medications at an outpatient facility, and had at least two months technology on a Likert Scale from 1 to 10 (where 1 = “Very hard
of standardised TB treatment remaining. Patients were excluded if to use” and 10 = “Very easy to use”).
they had a current or prior diagnosis of multidrug-resistant (MDR)-
TB or a severe mental illness. Consecutive patients presenting to Sample size
the clinic were invited to participate.
The primary outcome was the proportion of patients Assuming that 90% of patients would take all expected doses
completing all doses of self-administered treatment during the over a 2 month period of follow-up, and aiming to estimate the
study period, according to pill count by health workers. The proportion of treatment completion with a precision of 10%, we
secondary outcomes included the proportion of videos uploaded estimated that at least 35 patients would be required. We
as scheduled, and the proportion of patients discontinuing using aimed to recruit at least 10 people from each of the three study
VDOT. sites.
 T.A. Nguyen et al. / International Journal of Infectious Diseases 65 (2017) 85–89 87

Ethical issues Table 1

Baseline characteristics of study participants.

Participants provided written informed consent. Participants Variable Number Percentage

were given a small financial reimbursement to cover their travel (n) (%)
expenses to attend each visit. Ethical approval was provided by the Total patients enrolled 40 –
Human Research Ethics Committee at the University of Sydney and Male 30 (75.0%)
Age (median, IQR) 33.5 (22.5-42.5
the Ethics Committee of the Vietnam National Lung Hospital. AES
yearsa years)b
128-bit digital image encryption was used during data transfer to a Highest education level
secure server. Access to smartphones and the website used to University or equivalent 14 (35.0%)
review the videos were password protected. Upper secondary 18 (45.0%)
Lower secondary 4 (10.0%)
Primary 4 (10.0%)
Results
Current technology use
Mobile reception in house 39 (97.5%)
Participant characteristics Wifi in house 29 (72.5%)
Current usage of mobile phones
For internet access 28 (70.0%)
Between November 2016 and January 2017, among the 78
Playing games 15 (37.5%)
eligible patients invited to participate, 40 patients (51%) agreed to Taking photos 25 (62.5%)
participate in the study (Figure 1). This included 23 of 56 eligible Taking videos 25 (62.5%)
patients (50%) from the National Lung Hospital and 17 of 22 eligible Social networking 28 (70.0%)
patients (77%) from the two district clinics. Among the 38 non- Short messaging service (SMS) 30 (75.0%)
Other activities 19 (47.5%)
participants, 13 patients (34.2%) were unwilling to use a
Type of phone used in last month
smartphone, five patients (13.2%) refused to participate in research Smart phone 32 (80.0%)
study, two (5.3%) did not participate due to concerns about Non-smart phone 11 (27.5%)
confidentiality, two (5.3%) gave other reasons, and 16 (42.1%) did Tablet computer 3 (7.5%)
not provide a reason for their refusal. A median of 0 (interquartile Fixed line phone at home 2 (5.0%)
Fixed line at work 1 (2.5%)
range 0-7) days of therapy had been supervised by the nominated Number of phones used in last month 1 (1.0-1.0)
treatment supporter in the week preceding enrolment. (median, IQR)
The characteristics of study participants are shown in Table 1. Phone credit used in past month $6.60 ($4.40-$15.40)
Thirty-nine participating patients (97.5%) used a mobile phone ($USD) (median, IQR)
Phone used for the study
regularly prior to the study, and 32 (80.0%) patients had used a
Patient’s own smartphone 21 (52.5%)
smartphone in the previous month. The VDOT App was installed on Study phone 18 (45.0%)
the personal smartphones of 21 (52.5%) patients, while 18 (45.0%) Family member’s phone 1 (2.5%)
patients borrowed a study phone and one patient (2.5%) used the Phone used for the study
phone of a family member. Tuberculosis treatment regimen
First-line 34 (85.0%)
Retreatment 6 (15.0%)
Microbiological status at time of diagnosis with tuberculosis
Smear positive 37 (92.5%)
Smear negative, culture positive 2 (5.0%)
78 patients invited to Smear negative, PCR positive 1 (2.5%)
participate Abnormal chest radiograph 40 (100.0%)
HIV status
56 National Lung Hospital Positive 0 (0.0%)
11 District Clinic A Negative 12 (30.0%)
11 District Clinic B Not performed 28 (70.0%)
Home treatment supervisor was known by 34 (85.0%)
patient

38 patients a
Median.
declined to b
Interquartile range.
participate

40 patients enrolled
All patients reported that it was important to take their TB
23 at National Lung Hospital
7 at District Clinic A medications, and were concerned about the potential for harm if
10 at District Clinic B they did not take treatment.

Adherence with VDOT by pill count

2 patients
lost to follow-up The median duration of follow-up was 62 days (IQR 60-68 days).
The median proportion of doses taken by patients was 100% (IQR
98.4%-100%). Twenty-seven (71.1%) patients took every required
38 patients completed dose, according to pill-count. Four patients missed four or more
follow-up after 2 months doses (Table 2). Two participants did not complete follow-up.
22 at National Lung Hospital
7 at District Clinic A Adherence with uploading of videos
9 District Clinic B
A median of 88.4% (IQR 75.8% – 93.7%) of daily videos were
Figure 1. Flow diagram showing participation and follow-up during adherence correctly uploaded. Thirty-four (85%) patients missed less than
support with Video Directly Observed Therapy (VDOT). four video uploads during the follow-up period.
88 T.A. Nguyen et al. / International Journal of Infectious Diseases 65 (2017) 85–89

Table 2 attitudes toward the VDOT system after two months of use. The
Treatment adherence and technical difficulties during the intervention period.
median score for overall ease of use was 9 (IQR 9-10), where
Variable Number Percentage 1 = “Very hard to use” and 10 = “Very easy to use”.
(n) (%)
Total participants 40 Discussion
Daily doses missed over 2 months
0 33 (82.5%)
We have shown that VDOT is a feasible technology to support
1 4 (10.0%)
2 1 (2.5%)
adherence with TB treatment in Vietnam, a high prevalence setting
3 0 (0.0%) for the disease. Enrolled patients were able to record a high
4 2 (5.0%) proportion of daily videos, and indicated they would recommend
Days when video uploads missed over 2 months the technology to other patients. However, in this setting where
0 days 19 (47.5%)
self-administered therapy is the standard of care, only 51% of
1-4 days 15 (37.5%)
5-8 days 3 (7.5%) eligible patients at National and District clinics agreed to
9-12 days 1 (2.5%) participate in the study, despite the free availability of a
13 days and above 2 (2.5%) smartphone and the availability of technical support.
Lost mobile phone 1 (2.5%)
This study suggests that smartphone-based technologies could
Experienced technical difficulties using VDOT
Never 24 (80%)
be useful to support patients with TB, even in resource-limited
Rarely 3 (10.0%) settings. The scale-up of mobile-phone technologies has become
Sometimes 1 (3.3%) increasingly feasible, given the rapid decline in market prices of
Frequently 2 (6.7%) smartphones, the growing prevalence of smartphone ownership in
No response 10 (25.0%)
resource-limited settings (Poushter, 2016), and coverage of the
majority of the world’s population by mobile networks (World
Bank, 2017). This trend is likely to continue. However, technologi-
Technical issues relating to smartphone and app use cal solutions to adherence may not be suitable for all patients.
Given that TB predominantly affects those patients with a low
One loaned study phone was not returned (2.5%) and one socioeconomic status (Lonnroth et al., 2009), familiarity with this
loaned phone had minor damage which did not prevent VDOT use. technology may be more limited than in the general population.
Sixteen patients (40%) reported having some technical difficulties Older populations may also face challenges adapting to new
using the VDOT platform during the implementation period. technological tools to support adherence (Westerman and Davies,
Reasons given by patients for missing uploads included other 2000). However, we found most patients were able to learn to use
commitments, flat batteries, travel, technical difficulties, a the technology, after intensive initial training. A small number of
perception that internet access was required to upload videos, eligible patients expressed concerns that the digital video
or slow upload speeds. recording would be overly intrusive. This is consistent with other
Observation of dosing by research staff also identified three reports suggesting that privacy concerns could limit the uptake of
patients were taking TB treatment at a dose, or composition, that digital technologies by some people (DiStefano and Schmidt,
was inconsistent with the National Guidelines. In these cases, 2016). Further research is required to evaluate approaches that
research staff liaised with the treating doctors, who amended the minimize stigma and avoid intrusiveness of monitoring technolo-
prescribed regimen. gies.
Importantly, the measured treatment adherence in our study
Participant rating of VDOT exceeded the proportion of patients able to successfully upload
videos. This suggests that the intervention may still improve their
Participants rated the system highly, with 35 (87.5%) finding the adherence, and increase their engagement with health care
system easy to use, and 35 (87.5%) patients stating they would workers, even if technical problems sometimes prevent videos
recommend the method to other patients. Table 3 shows patient from being submitted.

Table 3
Patient attitudes towards the Video Directly Observed Therapy system.

Question Agree or strongly agree Percentage

(n) (%)
I found the system easy to usea,b 35 (87.5%)
I had problems recording a videoa 4 (10.0%)
I had problems uploading videosa 16 (40.0%)
I had problems using the system due to poor mobile phone reception 1 (2.5%)
Would you recommend the system to other patients
Yes 35 (87.5%)
No 0 (0.0%)
Don’t know 3 (7.5%)
Did not respond 2 (5.0%)
Technical condition of phone at end of follow-up
Fully functional 37 (92.5%)
Minor technical problem 1 (2.5%)
Did not respond 2 (5.0%)
Overall rating for usec
Ease of use (median, IQR)a 9.0 (9.0-10.0)
a
Out of 38 responses. 2 participants lost to follow-up.
b
1 respondent indicated “Don’t know/not applicable”.
c
At end of 2 month period. Rated out of 10, where 10 Is very easy.
 T.A. Nguyen et al. / International Journal of Infectious Diseases 65 (2017) 85–89 89

This study has a number of limitations. Firstly, the patient Acknowledgements

population was selected based upon those who were willing to use
the technology. Therefore, participants may have been more likely This project was supported by a Harry Windsor Research Grant,
to take treatment than the general patient population. Therefore, awarded by the Australian Respiratory Council. Dr Greg Fox was
the intervention itself may not have improved adherence. supported by a CJ Martin Fellowship (NHMRC Grant App ID
Secondly, we were also unable to compare treatment adherence 1054107). Professor Richard Garfein (University of California San
with VDOT to that without use of the technology. While accurate Diego) provided input into technical aspects of the study protocol,
estimates of adherence in Vietnam are not available, research from and provided advice about the use of the VDOT platform. Dr. Kelly
other Asian settings found that up to 30% of patients were non Collins (SureAdhere Mobile Technology Inc) provided technical
adherent (Liu et al., 2015). This is supported by other studies. assistance in implementing the SureAdhere VDOT platform.
Nevertheless, further appropriately controlled studies are required Professor Garfein is also a SureAdhere cofounder.
to evaluate the effect of VDOT upon adherence, compared to self-
administration of treatment. A third limitation was our use of pill References
count as an indirect measure of adherence, namely monthly pill
count, rather than daily electronic pill counting. Nevertheless, we Adane AA, Alene KA, Koye DN, Zeleke BM. Non-adherence to anti-tuberculosis
treatment and determinant factors among patients with tuberculosis in
observed a close correlation between the proportions of video northwest Ethiopia. PLoS One 2013;8(11)e78791.
uploads and pill count. This indicates that true adherence rates DiStefano MJ, Schmidt H. mHealth for tuberculosis treatment adherence: a
were, in fact, high. framework to guide ethical planning, implementation, and evaluation. Global
Health Sci Pract 2016;4(June (2)):211–21.
Building upon this study, further research is required to Garfein RS, Collins K, Munoz F, Moser [132_TD$DIFF]K, Cerecer-Callu P, Raab F, et al.
compare the effectiveness of VDOT, in combination with other Feasibility of tuberculosis treatment monitoring by video directly observed
adherence support strategies, in improving treatment outcomes. therapy: a binational pilot study. Int J Tuberc Lung Dis 2015;19(September
(9)):1057–64.
Adequately powered studies must evaluate the effect of adher- International Telecommunication Union. ICT development report and database.
ence on patient-important outcomes, including treatment com- 2017 Available from: http://data.worldbank.org/indicator/IT.CEL.SETS.P2. [Last
pletion and retention in care. In addition to smartphone-based accessed 4th August 2017].
Johnston JC, Campbell JR, Menzies D. Effect of intermittency on treatment outcomes
approaches, simpler SMS-based interventions may also be
in pulmonary tuberculosis: an updated systematic review and meta-analysis.
integrated within the TB control programmes. Further studies Clin Infect Dis 2017;(February (14)).
are required to establish the characteristics of patients who are Kaona FA, Tuba M, Siziya S, Sikaona L. An assessment of factors contributing to
likely to benefit from VDOT or alternative digital technologies, treatment adherence and knowledge of TB transmission among patients on TB
treatment. BMC Public Health 2004;4(December (29)):68.
and those who may respond better to traditional in-person Karumbi J, Garner P. Directly observed therapy for treating tuberculosis. Cochrane
monitoring. Database Syst Rev 2015;29(May (5))CD003343.
Importantly, use of data generated through digital adherence Liu X, Lewis JJ, Zhang H, Lu [135_TD$DIFF]W, Zhang S, Zheng G, et al. Effectiveness of
electronic reminders to improve medication adherence in tuberculosis
support technologies can be used by TB control programmes to patients: a cluster-randomised trial. PLoS Med 2015;12(September (9))
direct greater resources to the sub-populations identified as having e1001876.
a higher risk of non-adherence (Liu et al., 2015). Digital monitoring Lonnroth K, Jaramillo E, Williams BG, Dye [136_TD$DIFF]C, Raviglione M, Lonnroth
K, et al. Drivers of tuberculosis epidemics: the role of risk factors and social
can also provide real-time feedback to National TB Programmes, determinants. Soc Sci Med 2009;68(June (12))2240–6 [Review].
allowing them to monitor the effectiveness of adherence support Lutge EE, Wiysonge CS, Knight SE, Sinclair D, Volmink J. Incentives and enablers to
across their network. improve adherence in tuberculosis. Cochrane Database Syst Rev 2015;03
(September (9))CD007952.
In conclusion, VDOT is a feasible and acceptable method of Mirsaeidi M, Farshidpour M, Banks-Tripp D, Hashmi S, Kujoth C, Schraufnagel D.
adherence support among patients treated at both central and Video directly observed therapy for treatment of tuberculosis is patient-
district (local) levels of the Vietnamese health system. Expansion oriented and cost-effective. Eur Respir J 2015;46(September (3)):871–4.
Poushter J. Smartphone ownership and internet usage continues to climb in
of the use of digital technologies will be increasingly feasible, as
emerging economies. Pew Research Center; 2016.
the rapid global deployment of smartphones and mobile phone Story A, Garfein RS, Hayward A, Rusovich [137_TD$DIFF]V, Dadu A, Soltan V, et al.
networks continues (World Bank, 2017). As costs of mobile Monitoring therapy adherence of tuberculosis patients by using video-enabled
devices continue to plummet, new technological solutions electronic devices. Emerg Infect Dis 2016;22(3):538–40.
Suthar AB, Zachariah R, Harries AD. Ending tuberculosis by 2030: can we do it?. Int J
promise to overcome longstanding barriers to TB control, Tuberc Lung Dis 2016;20(September (9)):1148–54.
underpinning renewed global efforts to eliminate TB (Suthar Suwankeeree W, Picheansathian W. Strategies to promote adherence to treatment
et al., 2016). by pulmonary tuberculosis patients: a systematic review. Int J Evid Based
Healthcare 2014;12(March (1)):3–16.
Uplekar M, Weil D, Lonnroth K, Jaramillo [138_TD$DIFF]E, Lienhardt C, Dias HM,
et al. WHO’s new end TB strategy. Lancet 2015;385(May (9979)):1799–801.
Conflict of interest Wald DS, Butt S, Bestwick JP. One-way versus two-way text messaging on improving
medication adherence: meta-analysis of randomized trials. Am J Med 2015;128
The data collection, analysis and reporting of this study was (October (10)1139 e1-5.
Weaver MS, Lonnroth K, Howard SC, Roter DL, Lam CG. Interventions to improve
conducted by the authors, independently of the technology
adherence to treatment for paediatric tuberculosis in low- and middle-income
provider, SureAdhere. The authors did not receive any financial countries: a systematic review and meta-analysis. Bull World Health Organ
support from SureAdhere, nor did SureAdhere determine the 2015;93(Ocotober (10) 700-11B.
Westerman SJ, Davies DR. Acquisition and application of new technology skills: the
suitability of this manuscript for publication.
influence of age. Occup Med (Lond) 2000;50(September (7)):478–82.
World Bank. Mobile cellular subscriptions (per 100 people) - International
Telecommunication Union, World Telecommunication/ICT Development Re-
Author contributions port and database. 2017 Available from: http://data.worldbank.org/indicator/IT.
CEL.SETS.P2. [Last accessed 21st August 2017].
NTA, NVN, NBH and GJF contributed to the design, conduct, World Health Organization. Digital health for the End TB Strategy - an agenda for
action. 2015 WHO/HTM/TB/201521.
analysis and manuscript preparation. PMT, NTL and PDC contrib- World Health Organization. Global tuberculosis report 2016. 2016.
uted to the conduct of the study, collection of data and manuscript World Health Organization. Guidelines for the treatment of drug-susceptible
preparation. tuberculosis and patient care (2017 update). Geneva: WHO; 2017.