EVIDENCE SYNTHESIS

Strategies to promote adherence to treatment by

pulmonary tuberculosis patients: a systematic review
Wongduan Suwankeeree MSN, RN and Wilawan Picheansathian DNurs, RN

Faculty of Nursing, Chiang Mai University, Chiangmai, Thailand

ABSTRACT

Objective: The objective of this study is to review and synthesise the best available research evidence that
investigates the effectiveness of strategies to promote adherence to treatment by patients with newly diagnosed
pulmonary tuberculosis (TB).
Methods: The search sought to find published and unpublished studies. The search covered articles published from
1990 to 2010 in English and Thai. The database search included Cumulative Index to Nursing and Allied Health
Literature (CINAHL), EMBASE, Cochrane Library, PubMed, Science Direct, Current Content Connect, Thai Nursing
Research Database, Thai thesis database, Digital Library of Thailand Research Fund, Research of National Research
Council of Thailand and Database of Office of Higher Education Commission. Studies were additionally identified from
reference lists of all studies retrieved. Eligible studies were randomised controlled trials that explored different
strategies to promote adherence to TB treatment of patients with newly diagnosed pulmonary TB and also included
quasiexperimental studies. Two of the investigators independently assessed the studies and then extracted and
summarised data from eligible studies. Extracted data were entered into Review Manager software and analysed.
Results: A total of 7972 newly diagnosed pulmonary TB patients participated in 10 randomised controlled trials and
eight quasiexperimental studies. The studies reported on the effectiveness of a number of specific interventions to
improve adherence to TB treatment among newly diagnosed pulmonary TB patients. These interventions included
directly observed treatment (DOT) coupled with alternative patient supervision options, case management with DOT,
short-course directly observed treatment, the intensive triad-model programme and an intervention package aimed
at improved counselling and communication, decentralisation of treatment, patient choice of a DOT supporter and
reinforcement of supervision activities.
Conclusion: This review found evidence of beneficial effects from the DOT with regard to the medication adherence
among TB patients in terms of cure rate and success rate. However, no beneficial effect was found from DOT
intervention with increasing completion rate. In addition, the combined interventions to improve adherence to
tuberculosis treatment included case management with directly observed treatment short-course program, the
intensive triad-model programme and intervention package. These interventions should be implemented by
healthcare providers and tailored to local contexts and circumstances, wherever appropriate.
Key words: promote, pulmonary tuberculosis, treatment adherence
Int J Evid Based Healthc 2014; 12:316.

Background treatment short-course (DOTS) programmes and to

T argets for global tuberculosis (TB) control launched
by the WHO in 2006 are designed to detect at least
70% of new smear-positive cases in directly observed
Correspondence: Wilawan Picheansathian, Faculty of Nursing,
Chiang Mai University, 110 Indhavarorose Road, Muang, Chiangmai
50200, Thailand. Tel: +66 53 949007; fax: +66 53 894171; e-mail:
wilawan.p@nurse.cmu.ac.th
DOI: 10.1097/01.XEB.0000444614.17658.46
successfully treat at least 85% of detected cases.1 The
DOTS strategy has five operational components for
effective TB control, including political commitment;
diagnosis based on sputum smear microscopy; stand-
ardised short-course drug regimens; adequate and unin-
terrupted supply of drugs and other materials; close
monitoring, in which patients are directly observed daily
to ensure that every dose of recommended treat-
ment regimen is taken; and standardised recording

International Journal of Evidence-Based Healthcare 2014 University of Adelaide, Joanna Briggs Institute 3

2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
 W Suwankeeree and W Picheansathian
and reporting with sufficient feedback.2,3 To complete
treatment is usually an independent choice of patients
and described as adherence. Successful TB control is
heavily dependent on effective treatment of patients,
requiring adherence throughout the full course of treat-
ment.4 However, approximately half of TB patients do
not complete the treatment course under routine prac-
tice conditions.5 7 This low adherence to treatment by
TB patients has been associated with adverse outcomes,
including increased transmission rates of tubercle bacilli,
prolonged infectiousness, treatment failure and relapse,
drug resistance, and increased cost of TB control pro-
grammes.810 Therefore, early and accurate diagnosis
and effective treatment leading to cure are the core
elements of TB control.
There have been five systematic reviews related to TB
treatment. The result of a systematic review of random-
ised controlled trials (RCTs) from 1966 to 1996 indicated
that reminder letters, monetary incentives, health edu-
cation, and intensive supervision of staff in TB clinics
improve adherence to TB treatment. These should be
adopted in the health system, depending on their appro-
priateness to practice circumstances.8 A meta-analysis of
13 studies, including three RCTs, nine casecontrol
studies, and one cohort analytic study in 1999, indicated
that the directly observed treatment (DOT) and incen-
tives of food, clothing, books, and transportation were
effective in reducing the incidence of TB.11 On the
contrary, a systemic review of 11 randomised and
quasi-RCTs from 1966 to 2007 found no rigorous evi-
dence to support the conclusion that the use of DOT in
low-income and middle-income countries improves cure
or treatment completion in people with TB.12 The results
of nine RCTs from 1945 to 2008 indicated that both
reminder systems and late patient tracers, which rou-
tinely remind patients to keep an appointment, showed
benefits of the intervention in increasing incidence of
TB.13 In addition, a systematic review of 19 studies,
including six RCTs, five prospective cohort studies, seven
retrospective cohort studies and one pilot programme in
the United States and Canada published between 1997
and 2007, showed that adherence and completion rates
of treating latent TB infection are suboptimal across
high-risk groups, and no single intervention has shown
consistent effectiveness.10 However, these systematic
reviews did not focus on new cases of pulmonary TB.
In addition, some studies were not included in these
reviews.1418
It is critically important to clarify the effectiveness of
strategies to promote adherence to treatment by
patients with pulmonary TB in order to support evi-
dence-based practice. This review has evaluated the
4 International Journal of Evidence-Based Healthcare 2014 University of Adelaide, Joanna Briggs Institute
2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
clinical evidence available on the effectiveness of
strategies to promote adherence to treatment by
patients with pulmonary TB.
Definitions
Treatment completion rate is defined as the percentage
of patients who completed the required treatment
course but did not receive sputum examinations on at
least two occasions for cure detection.
Cure rate is defined as the percentage of patients who
completed treatment and had two negative sputum
examinations during treatment, of which one was at
the end of treatment.
Success rate is the percentage of patients who are
cured and those who have completed treatment.
DOT is defined as ingestion of anti-TB medications
that was directly supervised by a healthcare worker
(HCW), community member or lay health worker or
case manager, or family member who was trained to
do this.
The DOTS is the control strategy for TB promoted by
the WHO. The DOTS strategy is made up of five oper-
ational components, including political commitment,
diagnosis based on sputum smear microscopy, stand-
ardised short-course drug regimens, adequate and unin-
terrupted supply of drugs and other materials, close
monitoring in which patients are directly observed daily
to ensure drugs are taken (DOT), recording and reporting
with sufficient feedback.
Self-administered treatment (SAT) is defined as
unsupervised administration of anti-TB medications
by patients.
Self-supervision is defined as responsibility for treat-
ment adherence by patients without supervision by
another person, which is the same meaning of SAT.
Objectives
The specific aims of the review were to
(1) identify the existing strategies to promote adher-
ence to treatment by patients with pulmonary
TB and
(2) identify the best strategy to promote adherence to
TB treatment by patients with pulmonary TB.
Inclusion criteria
Types of participants
This review considered all studies that included adults
age 15 years at least diagnosed with smear-positive and
smear-negative pulmonary TB (regardless of HIV infec-
tion) in community settings who had never received
anti-TB drugs or had taken them for less than 1 month.

The focus was on new cases and excluded previously
treated patients because of the increased likelihood of
drug resistance and adverse outcomes such as treatment
failure in the re-treatment group, which could nullify a
treatment effect irrespective of the quality of treatment
supervision.
Types of interventions
Interventions of interest were those related to strategies
to promote adherence to treatment, including DOT,
DOTS, case management, intervention package, parti-
cipatory in-service training, food incentives, and inten-
sive triad-model programme.
Types of outcome measures
The outcomes of interest were treatment completion
rate, cure rate, and success rate.
Types of studies
This review considered any RCTs that examined the differ-
ent strategies used to promote adherence to treatment by
patients with pulmonary TB. Additionally, quasiexperi-
mental studies were considered for inclusion in the review
to enable the identification of current best evidence for
promoting adherence to the TB management.
Exclusion criteria
This review excluded articles that were expert opinion
and literature reviews.
Search strategy
The search strategy was designed to identify both pub-
lished and unpublished studies. Two reviewers inde-
pendently searched for the articles. A detailed search
strategy was developed to identify studies for inclusion
in this review as follows:
(1) An initial limited search included journal indexes
from MEDLINE and the Cumulative Index to
Nursing and Allied Health Literature (CINAHL). An
analysis of the text contained in the title, abstracts
and subject descriptors of relevant articles was
undertaken to identify additional keywords.
(2) A second search using all identified keywords
and index terms was then undertaken across all
included databases.
(3) Reference lists and bibliographies of all identified
articles were also searched for additional relevant
studies and source journals.
Keywords included tuberculosis, pulmonary
tuberculosis, sputum-positive tuberculosis, adherence,
compliance, concordance, treatment, anti-tuberculosis
International Journal of Evidence-Based Healthcare 2014 University of Adelaide, Joanna Briggs Institute
2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
EVIDENCE SYNTHESIS
medication, intervention, therapy, DOT, DOTS, health
education, home visit, self-administrated, self-supervised,
financial incentives, counselling, lay health workers, treat-
ment completion, completion rate and cure rate.
The time period of the search covered articles pub-
lished from 1990 to 2010 in English and Thai languages.
The database search included CINAHL, EMBASE,
Cochrane Library, PubMed, Science Direct, Current Con-
tent Connect, Thai Nursing Research Database, Thai
thesis database, Digital Library of Thailand Research
Fund, Research of National Research Council of Thailand
and Database of Office of Higher Education Commission.
In order to avoid publication bias, hand searching of
the most recent issues (January 1990 to December 2010)
of the following journals was undertaken for additional
references: International Journal of Tuberculosis and Lung
Disease, American Journal of Infection Control, Journal
of Infection, Thai Journal of Tuberculosis Chest Disease
and Critical Care, Journal of Thai Medical Association and
Journal of Health Science. The search for unpublished
studies included the following sources: dissertation
abstracts, proceedings of nursing and allied health con-
ferences held in Thailand and other countries and direct
communication with researchers.
Methods of the review
Critical appraisal
All studies that met the inclusion criteria were assessed
for methodological quality using standardised critical
appraisal tools from the Joanna Briggs Institute Meta-
Analysis of Statistics Assessment and Review Instrument
(http://joannabriggs.org/SUMARI). Two reviewers inde-
pendently appraised each study. Discrepancies in critical
appraisal were resolved at a meeting between reviewers.
Those studies had to meet the criteria to be included in
the review.
Data collection
Two reviewers independently extracted data, using the
standardised data extraction tool from the Joanna Briggs
Institute Meta-Analysis of Statistics Assessment and
Review Instrument (http://joannabriggs.org/SUMARI).
However, the reviewers were not blinded to the authors
of the studies under review.
Data synthesis
If two or more comparable studies were identified, data
were pooled in a statistical meta-analysis to determine
the effectiveness of the intervention by using the Review
Manager software (RevMan v. 5.2; The Cochrane Collab-
oration, The Nordic Cochrane Center, Copenhagen,
Denmark). Comparability of the studies was defined
5
 W Suwankeeree and W Picheansathian
by the population, interventions and outcome measures.
Double data entry was undertaken to minimise the risk
of data entry errors.
Heterogeneity between combined studies was tested
using the standard x2 test and visual inspection of the
graphic presentation of the results. Pooled statistics were
calculated using a fixed-effect model when there was no
statistically significant heterogeneity. If evidence of sig-
nificant heterogeneity was identified, a random-effects
approach to the analysis was used. Relative risk (RR) was
used for categorical outcomes data and their 95% con-
fidence intervals (CIs) were calculated for each study. If
statistical pooling of results was not appropriate, the
findings were summarised in narrative form.
Results
Description of studies
The initial search on the basis of keywords yielded a total
of 1341 papers; however, a substantial number of these
articles did not address the objective of this review. Of
these, 1292 publications were excluded. A second-stage
elimination, based on closer scrutiny of the article
abstract and keywords in relation to the inclusion criteria,
resulted in 49 studies being deemed relevant for this
review. Following the reading of these full-text articles,
31 papers were excluded as they did not fulfil the
inclusion criteria. After detailed examination, 18 studies
qualified for inclusion based on methodological quality
assessment.
The 18 studies identified gave a combined total of
7972 patients who were newly diagnosed with pulmon-
ary TB regardless of HIV infection and starting a new
course of TB treatment, or who had taken anti-TB drugs
for less than 4 weeks. The majority (7621) were sputum
smear-positive cases, 191 cases were sputum smear-
negative15 and 160 cases of unknown status.19 All
studies used daily treatment throughout, except the
study in India20 which used the three-times-a-week
treatment both in the intensive and in the continuation
phases. Ten studies were RCTs15,1719,2126 and eight
used quasiexperimental designs.5,14,16,20,27 29 Of these,
16 were published in English5,1427,30 and two in
Thai.28,29 The number of participants in each study
ranged from 89 to 1522 patients aged 15 years at
least. Seventeen of the 18 trials were conducted in
low-income and middle-income countries including
India,20 Nepal,25 Pakistan,21 Taiwan,14 Tanzania,26
Timor-Leste,15 Thailand16,23,27 30 and Africa.1719,22,24
One trial was conducted in a high-income country, USA.5
The outcomes of interest in this review were direct
methods, including treatment completion rate, cure rate
and success rate. Many studies were excluded from this
6 International Journal of Evidence-Based Healthcare 2014 University of Adelaide, Joanna Briggs Institute
2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
review as their outcome was measured either as sputum
conversion rate after receiving TB treatment for 2 or
3 months or as a percentage of the medication taken.
The extent to which these intermediate outcomes cor-
relate with actual drugs taken is unknown. However,
clinical cases could have higher completion rates and
lower rates of failure related to misclassification from
overdiagnosis cases. This could influence the chance of
demonstrating a treatment effect. The stages of search-
ing, inclusion and exclusion of references for this review
are shown in Fig. 1.
Methodological quality of randomised
controlled trials
All trials were assessed using the JBI Critical Appraisal
tools. Only Lewin et al.18 and Kamolratanakul et al.23 met
all 10 criteria for methodological quality. Owing to the
nature of the intervention, it was not possible to conceal
assignment to the participant in seven trials.17,19,21,22,2426
Potentially reIevant articles
identified by Iiterature search
(n = 1341)
Articles excluded after abstract
evaluation (n = 1292)
Articles retrieved for detailed examination (n = 49)
Articles excluded after review of
full article (n = 31)
- Measured inappropriate outcome
(n = 9)
- Included patients who did not
meet inclusion criteria (n = 14)
- NonRCTs or quasiexperimental
studies (n = 4)
- Unknown patient age and illness
status (n = 3)
- Published in Spanish (n = 1)
Articles included in the systematic review
(n = 18)
- Randomized controlled trials (n = 10)
- Quasiexperimental studies (n = 8)
Figure 1. Flow chart for identification of trials for inclusion
and exclusion.

One trial22 did not conceal the treatment allocation
because of the impossibility of concealing assignment
results to the assessor at the study site. However, assessors
were not involved in the design and implementation of
the intervention or in the final data analysis. A study by
Lwilla et al.26 also did not conceal the allocation to treat-
ment groups from the allocator, and a study by Clarke
et al.22 was unclear on this criteria. A study by Martins
et al.15 did not include the outcomes of participants who
withdrew from the study in the analysis.
All trials use appropriate statistical analysis. Power
analysis on sample size calculations was reported in nine
trials.15,1719,21,22,2426 Study groups were identically
treated (apart from the interventions), and outcomes
appeared to be measured reliably in all studies. In each
study, attempts were made to control confounding
factors and ensure that any positive outcomes detected
were the result of the intervention. All RCTs used suitable
randomisation methods such as cluster randomisation,
block randomisation, stratified randomisation and
randomisation sequence generated by computer algor-
ithm.
Methodological quality of quasiexperimental
studies
All of the eight quasiexperimental studies met five of the
10 criteria except blinding, and six studies5,16,20,27,29,30
did not randomly assign participants to treatment
and control groups. These studies used convenience
sampling or purposive sampling depending on the avail-
ability of the patients who sought treatment at the study
site. Although randomisation methods were not used
in quasiexperimental studies, their quality was ensured
through comparison groups. The outcomes were
assessed using objective criteria and in a reliable manner
in all of the included studies. Appropriate statistical
analysis was employed in all included studies.
DOT SS
Study or subgroup Events Total Events Total Weight
Akkslip 1999 184 216 78 110
Kungsaworn 1997 42 51 46 61
Total (95% CI) 267 171
Total events 226 124
Heterogeneity: 2 = 0.65, df = 1 (P = 0.42); I2 = 0%
Test for overall effect: Z = 2.82 (P = 0.005)
Figure 2. Cure rate Forest plot comparison: directly observed treatment (DOT) vs. self-supervision (SS). CI, confidence
interval.
International Journal of Evidence-Based Healthcare 2014 University of Adelaide, Joanna Briggs Institute
2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
EVIDENCE SYNTHESIS
Effect of interventions
The findings of this review are discussed according to the
specific interventions used in the identified research and
their comparison with different control groups. The
results are broadly categorised into studies that eval-
uated DOT/DOTS, case management, intervention pack-
age, participatory in-service training, food incentives and
intensive triad-model programme.
Directly observed treatment
Directly observed treatment vs. self-
supervision
Cure rate
An RCT23 (836 participants) conducted in Thailand dem-
onstrated that cure rates of newly diagnosed pulmonary
TB patients who received DOT by individual patient
supervisors (76%) were significantly higher than the
rates of those on self-supervision (67%). This result
was consistent with two quasiexperimental studies27,29
(438 participants) conducted in Thailand that reported
cure rates were higher in the DOT group than in those on
self-supervision. When results from the two quasi-
experimental studies27,29 were combined, higher cure
rates among newly diagnosed pulmonary TB patients
who received DOT were statistically significant com-
pared with those on self-supervision (RR 1.17, 95% CI
1.051.30, P 0.005] (Fig. 2).
Completion rate
An RCT23 (836 participants) demonstrated that the com-
pletion rates of newly diagnosed pulmonary TB patients
who received DOT (7.7%) were similar to the rates of
those on self-supervision (8.7%); the authors did not
report results statistically. This result was consistent with
two quasiexperimental studies27,29 (438 participants)
which demonstrated that the completion rates in the
DOT group were similar to those in the self-supervision
Risk ratio Risk ratio
M-H, fixed, 95% CI M-H, fixed, 95% CI
71.2% 1.20 [1.05, 1.37]
28.8% 1.09 [0.90, 1.32]
100.0% 1.17 [1.05, 1.30]
0.2 0.5 1 2 5
Favours SS Favours DOT
7
 W Suwankeeree and W Picheansathian

DOT SS Risk ratio Risk ratio

Study or subgroup Events Total Events Total Weight M-H, fixed, 95% CI M-H, fixed, 95% CI
Akkslip 1999 1 216 0 110 32.6% 1.53 [0.06, 37.36]

Kungsaworn 1997 0 51 1 61 67.4% 0.40 [0.02, 9.55]

Total (95% CI) 267 171 100.0% 0.77 [0.09, 6.47]

Total events 1 1

Heterogeneity: = 0.35, df = 1 (P = 0.56); I = 0%

2 2

0.001 0.1 1 10 1000

Test for overall effect: Z = 0.24 (P = 0.81)
Favours SS Favours DOT

Figure 3. Completion rate Forest plot comparison: directly observed treatment (DOT) vs. self-supervision (SS). CI, confidence
interval.

group. When results from the two quasiexperimental
studies27,29 were combined, the completion rates of
newly diagnosed pulmonary TB patients who received
DOT compared with the rates of those on self-super-
vision were not statistically significant (RR 0.77, 95% CI
0.096.47, P 0.81) (Fig. 3).
Success rate
An RCT23 (836 participants) found success rates of newly
diagnosed pulmonary TB patients who received DOT
(84%) were significantly higher than the rates of those on
self-supervision (76%). This result was consistent with
two quasiexperimental studies27,29 (438 participants)
which demonstrated that the success rates were higher
in the DOT group than in the self-supervision group.
When results from the two quasiexperimental stud-
ies27,29 were combined, newly diagnosed pulmonary
TB patients who received DOT had a small but statisti-
cally significant higher success rates compared with
those on self-supervision (RR 1.17, 95% CI 1.051.30,
P 0.005) (Fig. 4).
Subgroup analysis for outcomes
Directly observed treatment by healthcare
worker vs. self-supervision
Cure rate
The meta-analysis of two trials23,30 (778 participants)
demonstrated that there was no significant difference
in cure rates between newly diagnosed pulmonary
TB patients who received DOT by HCW and those on
self-supervision (RR 1.06, 95% CI 0.931.22, P 0.37)
(Table 1). But the meta-analysis from three quasi-
experimental studies5,27,28 (675 participants) demon-
strated that there were statistically significant higher
cure rates among newly diagnosed pulmonary TB
patients who received DOT by HCW compared with
those on self-supervision, although the difference was
small (RR 1.22, 95% CI 1.121.34, P < 0.0001) (Table 1).
Completion rate
The meta-analysis of two RCTs21,23 (778 participants)
with a fixed model demonstrated that there was no
statistical difference in the completion rates among

DOT SS Risk ratio Risk ratio

Study or subgroup Events Total Events Total Weight M-H, fixed, 95% CI M-H, fixed, 95% CI
Akkslip 1999 185 216 78 110 70.7% 1.21 [1.06, 1.38]

Kungsaworn 1997 42 51 47 61 29.3% 1.07 [0.89, 1.29]

Total (95% CI) 267 171 100.0% 1.17 [1.05, 1.30]

Total events 227 125

Heterogeneity: 2 = 1.11, df = 1 (P = 0.29); I2 = 10%

0.5 0.7 1 1.5 2
Test for overall effect: Z = 2.80 (P = 0.005)
Favours SS Favours DOT

Figure 4. Success rate Forest plot comparison: directly observed treatment (DOT) vs. self-supervision (SS). CI, confidence
interval.

8 International Journal of Evidence-Based Healthcare 2014 University of Adelaide, Joanna Briggs Institute

2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
 EVIDENCE SYNTHESIS

Table 1. Subgroup meta-analysis for outcomes

Subgroups Included studies OR (95% CI) P Heterogeneity
DOT by HCW vs. SS
Cure rate
RCTs 20, 22 1.06 (0.931.22) 0.37 No
Quasiexperimental studies 5, 26, 27 1.22 (1.121.34) 0.0001 No
Completion rate
RCTs 0, 22 0.95 (0.382.36) 0.92 No
Quasiexperimental studies 5, 27 0.44 (0.028.81) 0.59 Yes (P 0.03)
Success rate
RCTs 19, 20, 22, 23 1.07 (0.961.20) 0.21 No
Quasiexperimental studies 5, 26, 27 1.19 (1.101.29) 0.00001 No
DOT by CM vs. SS
Success rate
RCTs 22, 23 1.32 (0.782.23) 0.30 Yes (P 0.01)
DOT by FM vs. SS
Cure rate
RCTs 22, 22 1.02 (0.801.31) 0.85 Yes (P 0.02)
Completion rate
RCTs 20, 22 1.07 (0.701.63) 0.76 No
Success rate
RCTs 0, 22 1.07 (1.001.15) 0.04 No
DOT by HCW vs. DOT by CM
Cure rate
RCTs 21, 22, 23 0.94 (0.821.08) 0.39 No
Quasiexperimental studies 26, 30 1.06 (0.951.20) 0.30 No
Completion rate
RCTs 21, 22 0.48 (0.161.45) 0.20 No
Success rate
RCTs 21, 22, 23 0.86 (0.661.12) 0.27 Yes (P 0.03)
Quasiexperimental studies 26, 30 0.99 (0.891.09) 0.82 No
DOT by FM vs. DOT by CM
Success rate
RCTs 22, 24 1.05 (1.001.11) 0.04 No
DOT by FM vs. DOT by HCW
Cure rate
RCTs 20, 22 0.89 (0.771.03) 0.12 No
Quasiexperimental studies 26, 29 0.62 (0.123.36) 0.58 Yes (P < 0.000)
Completion rate
RCTs 20, 22 1.80 (0.814.02) 0.15 No
Quasiexperimental studies 26, 29 1.65 (1.072.55) 0.02 No
Success rate
RCT 20, 22 0.95 (0.831.07) 0.38 No
Quasiexperimental studies 26, 29 0.92 (0.581.46) 0.72 Yes (P 0.02)

CI, confidence interval; CM, case manager; DOT, directly observed treatment; DOTS, directly observed treatment short-course; FM, family member; HCW, healthcare
worker; OR, odds ratio; RCT, randomised controlled trial; SS, self-supervision.

newly diagnosed pulmonary TB patients who received
DOT by HCW compared with those on self-supervision
(RR 0.95, 95% CI 0.382.36, P 0.92) (Table 1). The results
of three quasiexperimental studies5,27,28 were inconsist-
ent. The results of one study were not suitable for meta-
analysis.27 The combined results of two studies5,28
(544 participants) showed that there was significant
heterogeneity between the studies for completion
rates (x2 4.47; P 0.03). Meta-analyses of these two
studies,5,28 performed using random-effects models,
showed no statistically significant difference in comple-
tion rates (RR 0.44, 95% CI 0.028.81, P 0.59) (Table 1).
Success rate
The meta-analysis of the four RCTs19,21,23,24 (1001 partici-
pants) with a fixed model demonstrated that there was
no significant difference in success rates among newly
diagnosed pulmonary TB patients who received DOT
by HCW compared with those on self-supervision
(RR 1.07, 95% CI 0.961.20, P 0.21) (Table 1). However,

International Journal of Evidence-Based Healthcare 2014 University of Adelaide, Joanna Briggs Institute 9

2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
 W Suwankeeree and W Picheansathian
the meta-analysis from three quasiexperimental stud-
ies5,27,28 (675 participants) demonstrated that there was
a statistically significant higher success rate among
newly diagnosed pulmonary TB patients who received
DOT by HCW compared with those on self-supervision
(RR 1.19, 95% CI 1.101.29, P < 0.00001) (Table 1).
Directly observed treatment by case manager
vs. self-supervision
Cure rate
An RCT in Thailand by Kamolratanakul et al.23 (466
participants) found that the cure rates among newly
diagnosis pulmonary TB patients who received DOT by
case manager (73%) were higher than the rates in those
on self-supervision (67%); the authors did not report
results statistically. This result was consistent with a
quasiexperimental study by Akkslip et al.27 who reported
only one newly diagnosed pulmonary TB patient who
received DOT by case manager and met the criteria of
cure (100%). This rate was higher than the rate in those
on self-supervision [70% (78/110)]; the authors did not
report results statistically. As these two studies used
different methodology, it is inappropriate to pool their
results in meta-analysis.
Completion rate
An RCT in Thailand by Kamolratanakul et al.23 (466
participants) indicated that the completion rates among
newly diagnosed pulmonary TB patients who received
DOT by case manager (5%) were lower than the rates in
those on self-supervision (8%); the authors did not report
results statistically. However, a quasiexperimental study
by Akkslip et al.27 found that there were no newly
diagnosed pulmonary TB patients who received DOT
by case manager or on self-supervision who met the
criteria of treatment completion (0/1 and 0/110, respect-
ively).
Success rate
The meta-analysis of two RCTs23,24 (516 participants)
with significant heterogeneity was performed using a
random-effects model (x2 6.29, P 0.01). There was
no statistically significant difference in success rates
among groups (RR 1.32, 95% CI 0.78 2.23, P 0.30)
(Table 1). This result was inconsistent with a quasi-
experimental study in Thailand by Akkslip et al.27 who
reported that there was only one newly diagnosed
pulmonary TB patient who received DOT by case
manager and met the criteria of success (100%). This
rate was higher than the rate in those on self-super-
vision [70% (78/110)]; the authors did not report
results statistically.
10 International Journal of Evidence-Based Healthcare 2014 University of Adelaide, Joanna Briggs Institute
2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
Directly observed treatment by family member
vs. self-supervision
Cure rate
The meta-analysis of the two RCTs21,23 (1101 partici-
pants) with significant heterogeneity was performed
using a random-effects model (x2 5.84, P 0.02). The
result indicated that there was no statistically significant
difference in the cure rates between groups (RR 1.02,
95% CI 0.081.31, P 0.85) (Table 1). On the contrary, a
quasiexperimental study by Akkslip et al.27 (304 partici-
pants) demonstrated that the cure rates among newly
diagnosed pulmonary TB patients who received DOT by
family member (86%) were higher than the rates in those
on self-supervision (70%); the authors did not report
results statistically.
Completion rate
The meta-analysis of the two RCTs21,23 (1101 partici-
pants) used a fixed model and demonstrated that there
was no statistically significant difference in completion
rates among newly diagnosed pulmonary TB patients on
self-supervision compared with those who received DOT
by family member (RR 1.07, 95% CI 0.701.63, P 0.76)
(Table 1). This result was consistent with a quasi-
experimental study27 (304 participants) which reported
only one newly diagnosed pulmonary TB patient
who received DOT by family member and none on
self-supervision who met the criteria of treatment com-
pletion (1/149 and 0/110, respectively).
Success rate
The meta-analysis of the two RCTs21,23 (1101 partici-
pants) used a fixed model and demonstrated that
there was statistically significant higher success rates
among newly diagnosed pulmonary TB patients who
received DOT by family member compared with those
on self-supervision (RR 1.07, 95% CI 1.001.15, P 0.04,
I2 63.0%) (Table 1). This result was consistent with a
quasiexperimental study by Akkslip et al.27 (304 partici-
pants), which demonstrated the success rates among
newly diagnosed pulmonary TB patients who received
DOT by family member (86%) were higher than the rates
in those on self-supervision control group (70%); the
authors did not report results statistically.
Directly observed treatment by healthcare
worker vs. directly observed treatment by case
manager
Cure rate
The meta-analysis of three RCTs23,26,27 (669 participants)
used a fixed model and found no statistical difference
for cure rates among newly diagnosed pulmonary TB
patients who received DOT by HCW compared with

those who received DOT by case manager (RR 0.94, 95%
CI 0.821.08, P 0.39) (Table 1). This result was consist-
ent with the meta-analysis from two quasiexperimental
studies20,27 (639 participants) which demonstrated no
significant difference for cure rates between newly diag-
nosed pulmonary TB patients who received DOT by HCW
and those received DOT by case manager (RR 1.06, 95%
CI 0.951.20, P 0.30) (Table 1).
Completion rate
The meta-analysis of two RCTs22,23 (147 participants)
used a fixed model and demonstrated no significant
difference for completion rates between newly diag-
nosed pulmonary TB patients who received DOT by
HCW and those who received DOT by case manager
(RR 0.48, 95% CI 0.161.45, P 0.20) (Table 1). Two
quasiexperimental studies20,27 examined the effect of
DOT by HCW on completion rates compared with DOT
by case manager. A study by Singh et al.20 showed that
the completion rates among newly diagnosed pulmon-
ary TB patients who received DOT by case manager (7%)
was higher than those who received DOT by HCW (2%);
the authors did not report results statistically. However, a
study by Akkslip et al.27 found that none of the newly
diagnosed pulmonary TB patients who received DOT by
HCW or those who received DOT by case manager
met the criteria of treatment completion (0/21 and 0/1,
respectively).
Success rate
The meta-analysis of the three RCTs2224 (216 partici-
pants) with significant heterogeneity was performed
using a random-effects model (x2 6.86, P 0.03). The
result demonstrated that the success rate was not stat-
istically significant between the groups (RR 0.86, 95% CI
0.661.12, P 0.27) (Table 1). This result was consistent
with two quasiexperimental studies20,27 (639 partici-
pants) which demonstrated no statistically significant
difference in success rates between newly diagnosed
pulmonary TB patients who received DOT by HCW and
those who received DOT by case manager (RR 0.99, 95%
CI 0.891.09, P 0.82) (Table 1).
Directly observed treatment by family member
vs. directly observed treatment by case
manager
Cure rate
An RCT by Kamolratanakul et al.23 (386 participants)
found no statistically significant difference in cure rates
among newly diagnosed pulmonary TB patients who
received DOT by family member (76%) compared with
those who received DOT by case manager (73%).
International Journal of Evidence-Based Healthcare 2014 University of Adelaide, Joanna Briggs Institute
2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
EVIDENCE SYNTHESIS
However, a quasiexperimental study by Akkslip et al.27
(195 participants) indicated that there was only
one newly diagnosed pulmonary TB patient who
received DOT by case manager and met the criteria of
cure (100%). This rate was higher than the rate in those
who received DOT by family member [(86% (167/194)];
the authors did not report results statistically. As these
two studies used different methodology, it is inappro-
priate to pool results in meta-analysis.
Completion rate
An RCT study by Kamolratanakul et al.23 (386 partici-
pants) found no statistically significant difference in
completion rates among newly diagnosed pulmonary
TB patients who received DOT by family member (7%)
compared with the rates in those who received DOT by
case manager (5%). This result was consistent with a
quasiexperimental study by Akkslip et al.27 (195 partici-
pants) which reported that there was only one newly
diagnosed pulmonary TB patient who received DOT by
family member and none who received DOT by case
manager who met the criteria of treatment completion
(1/194 and 0/1, respectively).
Success rate
The meta-analysis of the two RCTs23,25 (1293 partici-
pants) used a fixed model and demonstrated that there
was a statistically significant higher success rate among
newly diagnosed pulmonary TB patients who received
DOT by family member compared with those who
received DOT by case manager (RR 1.05, 95% CI 1.00
1.11, P 0.04) (Table 1). However, a quasiexperimental
study by Akkslip et al.27 (195 participants) demonstrated
that there was only one newly diagnosed pulmonary TB
patient who received DOT by case manager who met the
criteria of cure (100%). This rate was higher than the
rate in those who received DOT by family member [86%
(168/194)]; the authors did not report result statistically.
Directly observed treatment by family member
vs. directly observed treatment by healthcare
worker
Cure rate
The meta-analysis of the two RCTs21,23 (711 participants)
used a fixed model and demonstrated that there was no
statistically significant difference in cure rates among
newly diagnosed pulmonary TB patients who received
DOT by family member compared with those who
received DOT by HCW (RR 0.89, 95% CI 0.771.03,
P 0.12) (Table 1). Results of two quasiexperimental
studies27,30 (709 participants) were inconsistent. There
was significant heterogeneity (x2 21.78, P < 0.000)
11
 W Suwankeeree and W Picheansathian
when these two quasiexperimental studies27,30 were
pooled, so they were analysed through meta-analysis
using the random-effects model. The result indicated
that the difference in cure rates was not statistically
significant between groups (RR 0.62, 95% CI 0.12
3.36, P 0.58) (Table 1).
Completion rate
The meta-analysis of the two RCTs21,23 (711 participants)
used a fixed model and demonstrated that there was no
statistically significant difference in completion rates
among newly diagnosed pulmonary TB patients who
received DOT by family member compared with those
who received DOT by HCW (RR 1.80, 95% CI 0.814.02,
P 0.15) (Table 1). The results of two quasiexperimental
studies27,30 (709 participants) were inconsistent. The
meta-analysis of the two quasiexperimental studies27,30
used a fixed model and demonstrated that there were
statistically significant higher completion rates among
newly diagnosed pulmonary TB patients who received
DOT by family member compared with those who
received DOT by HCW (RR 1.65, 95% CI 1.072.55,
P 0.02) (Table 1).
Success rate
The meta-analysis of the two RCTs21,23 (711 participants)
used a fixed model and demonstrated that there was no
statistically significant difference in success rates among
newly diagnosed pulmonary TB patients who received
DOT by family member compared with those who
received DOT by HCW (RR 0.95, 95% CI 0.831.07,
P 0.38) (Table 1). Results of two quasiexperimental
studies27,30 were inconsistent. Analyses were adjusted
to the random-effects model (n 709) because of
heterogeneity of the studies (x2 5.89, P 0.02). The
meta-analysis of the two quasiexperimental studies27,30
demonstrated that the difference in the success rates
were not statistically significant between the groups (RR
0.92, 95% CI 0.581.46, P 0.72) (Table 1).
Case management
A study in Taiwan14 found that the TB patients who
received DOTS case management comprising hospital
education, direct daily observation in the first 2 months
and one home visit per week by the case manager had
better treatment completion rates than those who
received traditional case management comprising in-
hospital education and one home visit per month, and
those who did not receive any intervention (96.9 vs. 68.6
vs. 68.6%, P 0.007). In addition, the treatment success
rate of the TB patients who received DOTS case manage-
ment was significantly improved compared with those
12 International Journal of Evidence-Based Healthcare 2014 University of Adelaide, Joanna Briggs Institute
2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
who received traditional case management, and those
who did not receive any intervention (93.7 vs. 68.6 vs.
68.6%, P 0.023).
Food incentive
A study in Timor-Leste15 demonstrated that provision of
food had no significant beneficial or harmful impact on
the completion of treatment (76 vs. 78%, P 0.7), but did
lead to improved weight gain at the end of treatment
(10.1 vs. 7.5% improvement, P 0.04).
Intensive triad-model programme
A study in Thailand16 found that the intensive triad-
model programme can improve a patients adherence to
a TB treatment regimen. The triad-model emphasises the
roles of three key persons (healthcare provider, TB
patient and treatment supporter) and provides compre-
hensive health education about TB and the importance
of its treatment. The healthcare provider and treatment
supporter visited all patients at home once a month to
encourage them to take medication regularly under the
supervision of the healthcare provider. The success
rate of treatment was higher in the patients receiving
the intensive triad-model programme than those in the
control group (96.0 vs. 84.9%, P 0.057). Moreover,
the confirmed cure rate was also significantly higher
in the experimental group than in the comparison group
(95.3 vs. 78.9%, P 0.02).
Intervention package
A study in Senegal, West Africa,17 demonstrated treat-
ment success for 88% of the patients who received the
intervention package. The intervention included
reinforced counselling through improved communi-
cation between health personnel and patients, decen-
tralisation of treatment, patient choice of a DOT
supporter and reinforcement of supervision activities
compared with 76% in the patients who received the
usual TB control programme [adjusted risk ratio (RR) 1.18,
95% CI 1.031.34]. In addition, this study found that
choice of a DOT supporter among the patients family
members yielded better treatment outcomes than
having other DOT supporters.
Participatory in-service training vs. usual
care (directly observed treatment short-
course)
Lewin et al.18 undertook a study in South Africa to assess
the addition to the DOTS strategy of an experimental,
participatory in-service training programme for clinic
staff delivered by nurse facilitators and focused on
patient centeredness, critical reflection on practice and

quality improvement. The results indicated that the cure
rates in the intervention clinics following the interven-
tion were 49.1% compared with 51% in the control
clinics. In addition, the completion rate in the interven-
tion group was 17.4% compared with 15.9% in the
control group. However, these differences were not
statistically significant, and the findings of this trial
are inconclusive.
Discussion
Approximately half of the TB patients did not complete
the treatment course under routine practice con-
ditions;5 7 however, the average adherence level to
treatment among patients with HIV, infectious diseases
and pulmonary diseases was 88.35, 74.0 and 68.8%,
respectively. In addition, adherence to care for pulmon-
ary conditions is significantly lower compared with other
conditions (t 2.02, P 0.04).31 The effectiveness of
strategies to promote adherence to treatment by TB
patients requires further research.
Pooled results of RCTs and quasiexperimental studies
consistently indicate the evidence of beneficial effects
from DOT with increased medication adherence among
TB patients in terms of cure rate and success rate.
Although these effects were small, there are clinically
significant differences in overall public health and health
system, including decreased transmission, shortened
infectiousness, prevented treatment failure and relapse,
which induce drug resistance and mortality, and
decrease cost of TB treatment and control. However,
no beneficial effects were found from DOT intervention
with increased completion rates. This finding is similar to
a review conducted by Parent,11 which indicated that
DOT was effective in promoting adherence to and com-
pletion of TB treatment. But the two reviews previously
published on adherence to treatment of latent TB infec-
tion differ from this review. A review of evidence in the
United States and Canada demonstrated that no single
intervention has been consistently effective in improv-
ing adherence to treatment for latent TB infection,
including DOT.10 The second review by Volmink and
Garner12 found no assurance that the routine use of DOT
in low-income and middle-income countries improves
cure or treatment completion in people requiring treat-
ment for clinically active TB or preventing active dis-
eases. This difference may be because of defining
different participants and outcome measures. However,
it is essential that all implementation of DOT strategies
with patients in the communities must identify and
remove constraints of access to care. Therefore, DOT
should be modified to suit local situations.10 It is import-
ant to devise treatment strategies that lessen financial
International Journal of Evidence-Based Healthcare 2014 University of Adelaide, Joanna Briggs Institute
2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
EVIDENCE SYNTHESIS
burdens on patients, keep the impact of stigma to a
minimum and give patients improved access to care. The
variants of DOT differ in important ways in terms of who
is being observed, where the observation takes place
and how often the observations occur.32 A variety of
supervision options have been explored, such as
supervision by family members, HCWs and community
members.
There was no significant difference in cure rates,
completion rates, and success rates among pulmonary
TB patients who received DOT by a community member
or family member or HCW. This finding is similar to the
reviews conducted by Volmink and Garner,12 which
indicated that there is no evidence showing that one
form of direct observation is better than another. Never-
theless, two RCTs23,25 found that the success rates of
pulmonary TB patients who received DOT by a family
member were significantly higher than the rates of those
who received DOT by a community member. This result
was inconsistent with a quasiexperimental study by
Akkslip et al.,27 which demonstrated that the success
rate among newly diagnosed pulmonary TB patients
who received DOT by case manager were higher than
the rates in those who received DOT by family member.
However, this quasiexperimental study was conducted
with a small sample size (195 participants). In addition,
the findings of three studies24,25,27 showed that family
member DOT and community DOT strategies can both
reach the WHO target for treatment success. This
strategy may be suitable for hard-to-access areas where
TB patient services are becoming increasingly over-
loaded and there are many different health programmes
requesting HCWs effort and time.
As DOTS in a health facility is not always convenient
and accessible to TB patients, it is necessary to explore
additional options. One option is to have a family mem-
ber supervise DOT. Using family observation, combined
with intensive supervision and home visits, has achieved
high cure rates; however, family members may not
understand the need to provide consistent treatment.
Despite the best educational efforts of healthcare staff,
there may be limited understanding of, or confidence in,
the efficacy of prescribed medicines. If adherence to
treatment creates tension in the family, the simplest way
to eliminate the source of tension is to discontinue
treatment observation. Therefore, family members can
potentially be effective treatment observers but only
within the restrictions that required close monitoring of
all aspects of the treatment delivery system through
frequent home visits by health facility staff.27,33
The most common accompanying interventions with
DOT are improved accessibility of services, increased
13
 W Suwankeeree and W Picheansathian
availability of drugs, changes in drug regimens, patient
incentives, tracing of patients who default and outreach
efforts.8 However, there have been problems with this
approach, most likely because of insufficient communi-
cation between the centres and the various agents of the
primary healthcare structure. One study demonstrated
that the intervention package based on improved
patient counselling and communication between health
personnel and patients, decentralisation of treatment,
patient choice of DOT supporter and reinforcement of
supervision activities led to improvement in patients
successfully completing the 8-month course of treat-
ment.17 This result is consistent with a systematic review
conducted by Haynes et al.,34 which showed that the
interventions that were effective for long-term care were
complex, including combinations of more convenient
care, information, reminders, self-monitoring, reinforce-
ment, counselling, family therapy, psychological therapy,
crisis intervention, manual telephone follow-up and
supportive care.
Food incentives did not result in a significant
improvement in adherence to treatment or successful
completion of treatment.15 This result was inconsistent
with a review conducted by Parent,11 which indicated
that DOT and incentive components such as food, cloth-
ing, books and transportation were frequently found to
be the most effective factors in treatment completion for
pulmonary TB patients. The only outcome significantly
associated with the intervention was weight gain. There-
fore, a food intervention may be worth considering in
patients with TB who are malnourished. For a variety
of patient populations, including alcoholic patients, sub-
stance abuse patients, homeless persons and patients
infected with HIV, a combination of multiple incentives
was found to be effective.
TB case management combined with the imple-
mentation of DOT in the first 2 months could effectively
improve the adherence of TB patients to treatment and
increase the patients completion and treatment success
rates. Clinical nurses can make a significant contribution
to healthcare delivery by using this model to oversee and
monitor TB patients medicine intake and medical care to
ensure their adherence and improve the patients treat-
ment completion rates. The model emphasises the
participation of key persons, a comprehensive TB health
education and visits to all patients at home once a month
as key to improving TB cure rates.16
Healthcare workers can play a key role in supporting
adherence to treatment, justifying the training com-
ponent of the tested strategy and promoting improved
counselling. But one study indicated that staff training
did not seem to improve TB treatment outcomes,18
14 International Journal of Evidence-Based Healthcare 2014 University of Adelaide, Joanna Briggs Institute
2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
possibly because of a range of health system barriers
that were not addressed by the training programme or
because of other unknown or unmeasurable factors.
Therefore, a training programme should combine with
interventions to address other barriers to clinic and
organisational change (e.g. shortage of experienced
staff).
This review supports the results from previous sys-
tematic reviews of qualitative research. The review
showed an absence of any evidence against DOT com-
pared with people treating themselves at home.32 How-
ever, this review indicated that self-supervision or SAT
promoted adherence to treatment among TB patients to
a lesser extent than DOT. Appropriately trained health-
care providers will be able to anticipate patient adher-
ence and therefore those suitable for self-supervision or
SAT should be assigned. Educational programmes should
be undertaken to educate private providers regarding
suitable patients for SAT; all patients with newly diag-
nosed TB should be evaluated by the public health
department for possible assignment to DOT.
Limitations of the review
This review has some limitations. First, it is limited to
evaluating outcomes within adult populations. Studies
with adolescents and children were not included as they
face significantly different issues in the context of treat-
ment adherence, particularly with parental involvement
in adherence. Secondly, focus was on studies with new
pulmonary TB patients in order to identify successful
strategies aimed at improving adherence among this
group of TB patients. Finally, many studies were
excluded from this review because they were not
designed specifically to assess treatment completion
rates, cure rates and success rates but rather to assess
sputum smear conversion rates in the second or third
month of treatment.
Conclusion
Several adherence interventions have been developed
to improve treatment for TB infection. This review found
evidence of benefits from a number of specific inter-
ventions to improve adherence to TB treatment among
newly diagnosed patients, including DOT with patient
choice of a DOT supporter, case management with DOT
and the intensive triad-model programme. In addition,
the intervention package based on improved patient
counselling and communication, decentralisation of
treatment, patient choice of a DOT supporter and
reinforcement of supervision activities could be gener-
alised in the context of TB control programmes in
resource-poor countries. These should be implemented

by healthcare providers and tailored to local contexts
and circumstances, wherever appropriate.
Implications for practice
There is evidence supporting the use of DOT to improve
adherence to TB treatment among newly diagnosed TB
patients. A frequent objection to DOT is that daily
observation of all patients by healthcare professionals
is not a feasible approach for low-income countries,
where the financial means to employ and train the
requisite staff are unavailable. This option cannot be
used by a large number of patients in rural areas who
may live far away from the nearest health centre. Giving
patients alternative supervision options that are con-
venient and accessible, such as community or family
members, may have contributed to the comparatively
favourable results in improving adherence to treatment.
Facilitation of the role of family or community members
in DOT involved training by HCWs and close supervision
through frequent home visits by health facility staff. In
areas in which patients live far from health centres,
access to drugs would be improved through decentral-
isation of treatment.17 Therefore, it would be beneficial
to shift the treatment of all TB patients to facilities within
the primary healthcare structure. However, this would
need to be well planned and tailored to local contexts
and circumstances.
However, DOT alone may be ineffective in the fight
against TB. Multiple components might account for the
success of DOT programmes. DOT coupled with food
incentives may be worth considering in patients with TB
who are malnourished at diagnosis.
Case management combined with DOTS should be
used for improving adherence to treatment among
newly diagnosed TB patients. This approach should
be implemented in the first 2 months as the adher-
ences of subjects declined with time. A TB case
management team should be set up at the hospital
and in community settings. The keys elements of case
management should include the facilitation of treat-
ment plans comprising education, direct daily obser-
vation in the first 2 months and one home visit per
week by the case manager.
Patients need to understand how their treatment is to
be organised. Therefore, it is essential that formalised
educational programmes should be integrated into TB
prevention and treatment programmes. To implement
comprehensive health education about TB and the
importance of treating it, the participation of key persons
including a healthcare provider, TB patient and treat-
ment supporter (the intensive triad-model programme)
could be helpful in improving TB cure rates.
International Journal of Evidence-Based Healthcare 2014 University of Adelaide, Joanna Briggs Institute
2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
EVIDENCE SYNTHESIS
Implications for research
Our review shows the need for further large-scale studies
on adherence to treatment by newly diagnosed pulmon-
ary TB patients. It may also be worth comparing DOT to
other strategies aimed at improving adherence. Factors
that determine its usefulness in various settings require
further study.
Further strategies, especially those that are feasible in
developing countries or countries with limited resources,
should be evaluated in RCTs before being introduced
into routine practice. Additionally, further research is
required that investigates DOT vs. self-supervision to
determine ongoing treatment success and re-treatment
rates.
Acknowledgements
The authors sincerely thank The Joanna Briggs Institute
for supporting this review. The review received financial
support from the Thailand Centre for Evidence-Based
Nursing and Midwifery, Faculty of Nursing, Chiang Mai
University, Thailand.
The author reports no conflicts of interest.
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