Elsevier

The Lancet

Volume 355, Issue 9212, 15 April 2000, Pages 1345-1350
The Lancet

Review
Directly observed therapy and treatment adherence

https://doi.org/10.1016/S0140-6736(00)02124-3Get rights and content

Summary

Direct observation of patients taking their medication is a strategy to improve completion rates for tuberculosis treatment, but the programmes to implement this approach consist of a complex array of inputs aimed at influencing adherence. Policy makers need a clear understanding of these inputs to succeed. We systematically identified and reviewed published reports of direct observation therapy (DOT) programmes and compared inputs with WHO's short-course DOT programme. DOT programmes frequently consist of more than the five elements of WHO's strategy, including incentives, tracing of defaulters, legal sanctions, patient-centred approaches, staff motivation, supervision, and additional external funds. Focusing on direct observation as a key factor in the promotion of adherence seems inappropriate. Multiple components might account for the success of DOT programmes, and WHO should make these explicit.

Section snippets

Search for reports

We searched MEDLINE from 1996 to 1999, on “directly observed therapy” (textword) and “tuberculosis” (textword or MesH). In addition we searched EMBASE up to November, 1999, and the Cochrane Controlled Trials Register published in the Cochrane Library (issue 4, 1999). We also searched reference lists of original articles and reviews (JV). Data extraction was done by two researchers working independently and differences were resolved by discussion.

We included any study that had assessed the

Description of studies

Of the 111 studies identified, 32 describing 30 programmes or programme clusters met our selection criteria (table 1).4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 Most were from studies done in the USA (12) or South Africa (seven), and the rest were from the former Union of Soviet Socialist Republics (USSR, two), Cambodia (two), Nepal (one), Somalia (one), Mexico (one), Thailand (one), Philippines (one), China (one),

Analysis of inputs

Incentives of free food, clothes, or transportation tokens were provided in 11 programmes. In one US programme, patients received the equivalent of $US100 per month,21 and in another cigarettes were offered.28 Contracts, celebration of accomplishments with parties and certificates, health education, and help in obtaining housing, financial assistance, psychological support, and treatment for substance abuse were also common.

A unique feature of the US programmes, mentioned in five reports, was

Effectiveness of DOT programmes

All 32 studies mentioned the specific strategy of direct observation by a health worker or delegate of patients taking their drugs (table 2). 13 studies recorded a strengthened reporting system. 11 studies mentioned an improved drug supply, nine studies mentioned improvement in laboratory studies, and eight commented on political commitment.

The main purpose of this review was to summarise inputs as described in research reports of DOT programmes. We did not intend to summarise the quality of

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