Evaluation of implementation and effectiveness of digital adherence technology with differentiated care to support tuberculosis treatment adherence and improve treatment outcomes in Ethiopia: a study protocol for a cluster randomised trial.

BACKGROUND: Digital adherence technologies (DATs) are recommended to support patient-centred, differentiated care to improve tuberculosis (TB) treatment outcomes, but evidence that such technologies improve adherence is limited. We aim to implement and evaluate the effectiveness of smart pillboxes and medication labels linked to an adherence data platform, to create a differentiated care response to patient adherence and improve TB care among adult pulmonary TB participants. Our study is part of the Adherence Support Coalition to End TB (ASCENT) project in Ethiopia. METHODS/DESIGN: We will conduct a pragmatic three-arm cluster-randomised trial with 78 health facilities in two regions in Ethiopia. Facilities are randomised (1:1:1) to either of the two intervention arms or standard of care. Adults aged ≥ 18 years with drug-sensitive (DS) pulmonary TB are enrolled over 12 months and followed-up for 12 months after treatment initiation. Participants in facilities randomised to either of the two intervention arms are offered a DAT linked to the web-based ASCENT adherence platform for daily adherence monitoring and differentiated response to patient adherence for those who have missed doses. Participants at standard of care facilities receive routine care. For those that had bacteriologically confirmed TB at treatment initiation and can produce sputum without induction, sputum culture will be performed approximately 6 months after the end of treatment to measure disease recurrence. The primary endpoint is a composite unfavourable outcome measured over 12 months from TB treatment initiation defined as either poor end of treatment outcome (lost to follow-up, death, or treatment failure) or treatment recurrence measured 6 months after the scheduled end of treatment. This study will also evaluate the effectiveness, feasibility, and cost-effectiveness of DAT systems for DS-TB patients. DISCUSSION: This trial will evaluate the impact and contextual factors of medication label and smart pillbox with a differentiated response to patient care, among adult pulmonary DS-TB participants in Ethiopia. If successful, this evaluation will generate valuable evidence via a shared evaluation framework for optimal use and scale-up. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR202008776694999, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12241 , registered on August 11, 2020

Analysis of the Spatio-Temporal Variability of Precipitation and Drought Intensity in an Arid Catchment in South Africa

Water deficit is high and precipitation varies spatio-temporally in arid areas. This study was conducted to analyse the spatio-temporal variability of precipitation and drought intensity in an arid catchment in South Africa. The Soil and Water Assessment Tool (SWAT) was used to estimate the spatio-temporal precipitation where nine meteorological stations were used as input to the model. The model was calibrated and validated by regionalization with a physical similarity approach. SWAT only predicts precipitation at sub-basin level. Hence, the mean precipitation was further interpolated by using the inverse distance weighted method (IDW). The Mann–Kendall trend test shows that there was no trend in annual precipitation whereas in the monthly precipitation there was a 0.01 mm decrease. Daily precipitation varied from 0.1 to 4 mm whereas in a monthly basis, it varied from 6 mm (September) to 43.4 mm (February). The annual precipitation varied from 169 mm (1983) to 415 mm (2003) with a long-term mean of 280.8 mm. Precipitation is also highly variable in space throughout the catchment. Generally, annual precipitation decreased from north to south; however, during the winter season, the reverse was true due to the influence of rain-bearing condition from the south- western direction. Based on the aridity index (AI), the catchment is categorized as arid. The SPI shows that the 1983 drought was the worst whereas the 2003 and 2004 years were relatively wet. The results from this study provide baseline information for further research in climate change adaptation and environmental monitoring programs in the region

Community Health Seeking Behavior for Suspected Human and Animal Rabies Cases, Gomma District, Southwest Ethiopia.

BACKGROUND:Timely presentation to appropriate health service provider of sick animals/humans from zoonotic diseases like rabies is important for early case/outbreak detection and management. However, data on community's health seeking practice for rabies in Ethiopia is limited. Therefore the objective of this study was to determine community's health seeking behavior on rabies, Southwest Ethiopia. METHODS:A cross-sectional survey was conducted from January 16-February 14, 2015 to collect data from 808 respondents where the respondents were selected using multistage sampling technique. Data were collected using interviewer administered structured questionnaire by trained epidemiology graduate level students. Data were entered to Epidata version 3.1 and analyzed using SPSS version 20 for windows. RESULT:Eight hundred three (99.4%) respondents participated in the study. Out of 28 respondents who reported their family members' exposure to rabies, 8 of them replied that the exposed family members sought treatment from traditional healers. More than nine in ten respondents perceived that humans and domestic animals with rabies exposure should seek help of which 85% of them suggested modern health care facilities as the preferred management option for the sick humans and domestic animals. However, among those who reported sick domestic animals, near to 72% of them had either slaughtered for human consumption, sold immediately, visited traditional healer, given home care or did nothing for the sick domestic animals. CONCLUSION:Majority of the respondents had favorable perception of seeking treatment from modern health care facilities for rabies. However, significant number of them had managed inappropriately for the sick domestic animals from rabies. Hence, raising awareness of the community about management of sick domestic animals from rabies and the need for reporting to both human and animal health service providers is needed

Socio-demographic and economic characteristics of respondents in Gomma district, Southwest Ethiopia, January 16-Februay 14, 2015 (N = 803).

<p>Socio-demographic and economic characteristics of respondents in Gomma district, Southwest Ethiopia, January 16-Februay 14, 2015 (N = 803).</p

General health seeking behavior of households for sick family members and domestic animals in Gomma district, Southwest Ethiopia, January 16-Februay 14, 2015.

<p>General health seeking behavior of households for sick family members and domestic animals in Gomma district, Southwest Ethiopia, January 16-Februay 14, 2015.</p

Respondents’ actual health seeking behavior for rabies in human and domestic animals, Gomma district, Southwest Ethiopia, January 16-Februay 14, 2015.

<p>Respondents’ actual health seeking behavior for rabies in human and domestic animals, Gomma district, Southwest Ethiopia, January 16-Februay 14, 2015.</p

Evaluating the equity impact and cost-effectiveness of digital adherence technologies with differentiated care to support tuberculosis treatment adherence in Ethiopia: protocol and analysis plan for the health economics component of a cluster randomised trial

Abstract Background Tuberculosis remains a leading infectious cause of death in resource-limited settings. Effective treatment is the cornerstone of tuberculosis control, reducing mortality, recurrence and transmission. Supporting treatment adherence through facility-based observations of medication taking can be costly to providers and patients. Digital adherence technologies (DATs) may facilitate treatment monitoring and differentiated care. The ASCENT-Ethiopia study is a three-arm cluster randomised trial assessing two DATs with differentiated care for supporting tuberculosis treatment adherence in Ethiopia. This study is part of the ASCENT consortium, assessing DATs in South Africa, the Philippines, Ukraine, Tanzania and Ethiopia. The aim of this study is to determine the costs, cost-effectiveness and equity impact of implementing DATs in Ethiopia. Methods and design A total of 78 health facilities have been randomised (1:1:1) into one of two intervention arms or a standard-of-care arm. Approximately 50 participants from each health facility will be enrolled on the trial. Participants in facilities randomised to the intervention arms are offered a DAT linked to the ASCENT adherence platform for daily adherence monitoring and differentiated response for those who have missed doses. Participants at standard-of-care facilities receive routine care. Treatment outcomes and resource utilisation will be measured for each participant. The primary effectiveness outcome is a composite index of unfavourable end-of-treatment outcomes (lost to follow-up, death or treatment failure) or treatment recurrence within 6 months of end-of-treatment. For the cost-effectiveness analysis, end-of-treatment outcomes will be used to estimate disability-adjusted life years (DALYs) averted. Provider and patient cost data will be collected from a subsample of 5 health facilities per study arm, 10 participants per facility (n = 150). We will conduct a societal cost-effectiveness analysis using Bayesian hierarchical models that account for the individual-level correlation between costs and outcomes as well as intra-cluster correlation. An equity impact analysis will be conducted to summarise equity efficiency trade-offs. Discussion Trial enrolment is ongoing. This paper follows the published trial protocol and describes the protocol and analysis plan for the health economics work package of the ASCENT-Ethiopia trial. This analysis will generate economic evidence to inform the implementation of DATs in Ethiopia and globally. Trial registration Pan African Clinical Trial Registry (PACTR) PACTR202008776694999. Registered on 11 August 2020,  https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12241