Video Observed Therapy (VOT) for People with Tuberculosis (TB): A Scoping Review
1Departments of Clinical Science and International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
2Royal Liverpool University Hospital, Liverpool, United Kingdom
3Instituto Nacional de Saúde, Marracuene, Mozambique
4Faculdade de Medicina, Eduardo Mondlane University, Maputo, Mozambique
5World Health Organization Collaborating Centre on Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
#Corresponding Author: Dr Tom Wingfield, Email: tom.wingfield@lstmed.ac.uk X: @drtomwingfield, Room W-01-34 Wolfson Building, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, United KingdomAbstract
Background
Tuberculosis (TB) remains a significant cause of morbidity and mortality globally, disproportionately affecting low- and middle-income countries (LMIC). Accessing Directly Observed Therapy (DOT) is associated with out-of-pocket costs and stigma. Video-observed therapy (VOT) is an alternative to DOT but evidence from LMIC with high TB burden is limited. To make recommendations for future VOT-related research and inform the design of a pilot implementation of VOT for people with multi-drug resistant TB (MDR-TB) in Mozambique, we did a scoping review of the evidence on VOT for people with TB.
Methodology
We systematically searched five scientific databases and key grey literature repositories to identify eligible abstracts. Abstracts were reviewed and full-text records were identified and evaluated. Data from full-text records were extracted into four implementation theme categories: Feasibility, Acceptability, Cost, and Effectiveness (FACE). Content analysis was used to describe implementation successes and challenges, comparing VOT versus DOT where possible. The Crowe Critical Appraisal Tool (CCAT) was used to evaluate the quality of studies.
Results
In total, 66 records were identified: 47 primary research studies, 13 reviews, and six grey literature documents. All studies were graded as moderate to high quality and reported against at least one FACE category. Studies from urban settings (n=34) and HIC (n=33) predominated. Where measured and described, VOT implementation was reported to be feasible (43/43, 100%) and acceptable (43/44, 97%). Of the 18/20 (90%) studies describing cost data, VOT was reported to offer savings to the health system compared to DOT. Patient costs were under-reported. Of the 21/23 (91%) studies describing effectiveness to improve adherence to TB treatment, VOT was reported to be non-inferior to DOT.
Conclusion
In HIC settings, VOT was reported as feasible, acceptable, and similarly effective alternative to DOT. Further evidence on VOT is needed from LMIC with high TB burden.
Article notes
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
The author(s) received no specific funding for this work.
Introduction
Tuberculosis (TB) remains a major global public health challenge. In 2023, TB regained, from COVID-19, the position of the leading cause of death from a single infectious disease worldwide1,2. Most high TB burden countries are lower- and lower-middle-income countries (LMIC), which are disproportionately affected by TB-related morbidity and mortality, especially where HIV prevalence is high2,3. Without treatment, 10-year mortality from TB is approximately 70%3. Although shorter TB treatment regimens are effective in treating TB, most countries are still using antimicrobial regimens lasting up to 18 months to treat multi-drug resistant TB (MDR-TB), a leading cause of death from antimicrobial resistance (AMR). The high pill-burden and long treatment duration has clinical, psychological, and socio-economic consequences, challenging adherence. Treatment success rates for MDR-TB are estimated to be approximately 60%3. Suboptimal adherence increases the likelihood of adverse TB treatment outcomes including treatment failure, AMR, and onward transmission.
Providing support to people with TB to facilitate adherence to treatment can minimize adverse outcomes4. Directly Observed Therapy (DOT) has been recommended by the World Health Organization (WHO) as a method to improve TB treatment adherence. While some studies have suggested that DOT can increase adherence when compared to self-administered therapy (SAT), a Cochrane systematic review and meta-analysis found no significant differences in treatment success between DOT and SAT4. Facility-based DOT involves observation of medication doses by healthcare workers (HCW) at healthcare centres. This requires daily travel by people with TB and DOT may not be accessible for communities in remote locations, where travel to healthcare centres is challenging or unaffordable5. In many cases this results in high levels of SAT, especially during weekends when healthcare centres may be closed. Moreover, DOT may be associated with stigma and a loss of autonomy among people with TB6.
Video Observed therapy (VOT) is a potential alternative to DOT. In VOT, videos are live-streamed or uploaded for review by HCWs, either synchronously (at the time of medication ingestion) or asynchronously (the recording is reviewed after medication ingestion). VOT has been highlighted as an essential digital health tool to achieve the 2015 WHO End TB Strategy aims to eliminate TB7. In some studies8,9, VOT has shown promise in increasing treatment adherence. This may relate to VOT being more convenient than DOT because it allows people with TB to take their treatment from home, work, or another location, using their mobile device to record ingestion. Moreover, compared to an in-person DOT appointment at a healthcare centre, VOT can reduce travel time, health system costs, patient costs, and patients’ perceived stigma7,10,11.
Despite its potential, there is limited up-to-date evidence on the implementation and effectiveness of VOT in LMIC and amongst vulnerable groups, including people with MDR-TB or comorbidities. This evidence gap is particularly pertinent given the expansion of digital health technologies since the COVID-19 pandemic and the increase in mobile phone ownership, usage, and internet coverage in LMICs12. This scoping review aimed to gather, synthesise and critically appraise the latest evidence on VOT for people with TB globally in order to inform the design of a pilot implementation of VOT for people with MDR-TB in Mozambique (the “SAFEST-1 MDR-TB” study), and make recommendations for future research.
Methods
Study Design
A scoping review was considered the most suitable method to comprehensively gather evidence from both the scientific and grey literature, provide details on VOT platforms used, and encompass heterogeneous study types and resources13,14. The scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) guidance14.
The JBI and Cochrane recommended PICO (Population, Intervention, Comparison, and Outcome) was used to help inform the search strategy and inclusion criteria15. Population was adults, pregnant women, adolescents, and children with TB. Intervention was VOT for TB treatment adherence monitoring. Comparison was DOT, DOTS, or SAT vs VOT. Outcomes included feasibility, acceptability, costs, effectiveness, and reported success and challenges of implementation.
Inclusion Criteria
The inclusion criteria included: i) Accessible peer-reviewed scientific journal articles of any study design or published reports with the primary or co-primary aim of describing and/or evaluating and/or reviewing Video Observed Therapy (VOT) for people (adults and children) with tuberculosis (TB) of any type and in any country, and assessed to be of sufficient quality to facilitate suitable data extraction for meaningful content analysis and interpretation (detailed further below); ii) Reports, working papers, technical guidance, and other non-scientific literature appearing in the grey literature of key databases (detailed further below); iii) Publication between 1st of January 2000 and 1st of January 2023 – a timescale chosen because of the paucity of digital adherence technologies, video-phone applications, and mobile phone coverage prior to the year 2000; and iv) Publications in English, Portuguese, French, and Spanish languages, in which the research team collectively had suitable reading comprehension skills.
Search Strategy
We systematically searched Medline, Embase, PubMed, Google Scholar and Web of Science databases for relevant articles, supplemented by a grey literature search of key databases to identify records published between 1st January 2000 and 1st January 2023. Grey literature was identified from a pre-specified convenience sample of databases selected through the consensus of the research team. These included: the World Health Organisation (WHO), Centers for Disease Control and Prevention (CDC), European Centre for Disease Prevention and Control (ECDC), and WHO International Clinical Trials Registry Platform (ICTRP). Reference snowballing and citation tracking were used to complement and expand the search.
The search for records was conducted between 9th February 2023 and 31st March 2023. Duplicates were identified and removed. Titles and abstracts were reviewed by two team members independently, but not blinded, according to the inclusion criteria. Where there was disagreement, a third opinion was sought from a third reviewer. The full-text of selected records were uploaded to a password-protected online, “live” shared Excel spreadsheet stored on an LSTM cloud-based server. Only deidentified and anonymised secondary data was stored and used and there was no confidential participant information.
The quality of records selected for full-text review was evaluated using the Crowe Critical Appraisal Tool (CCAT)16. Based on previous research by our study team6, a decision was taken to pragmatically categorise CCAT scores (percentage score out of a total of 40 points) as follows: ≥30 points, 75%-100%, high quality; 20 to 29 points, 50%-74%, moderate quality; and <20 points, <50%, low quality.
Data Analysis
From included full-text records, we extracted aggregate sociodemographic data of participants, geographic and World Bank economic classification data (low, middle, high income) of study sites, data related to the VOT platforms used, and implementation data for content analysis on the challenges and success of VOT with relation to Feasibility, Acceptability, Cost, and Effectiveness (FACE) – categories decided a priori through study team consensus. Data were presented in narrative and tabular form.
Results
Study Selection
The search yielded 429 records: PubMed (n=138), Medline (n=79), Web of Science (n=100), Cochrane (n=7) and Google Scholar (n=105)(Figure 1). Of these, 160 were removed, mainly due to duplication, leaving 269 records to be screened. Following eligibility screening, 60 records were selected for full-text review. The complementary search of the pre-specified convenience sample of grey literature databases yielded 22 registered clinical trials and citation “snowballing” searching by manually reviewing references of the above 60 included studies found another six relevant studies; these two sources combined to identify a further six studies for full-text review (Figure 1).
Study Characteristics
The 66 records selected consisted of: 47 primary research studies (Table 1), 13 review-type studies including systematic reviews, scoping reviews, and narrative/non-systematic reviews (Table 2), and six grey literature documents (Table 3).
Most studies (n=34) were conducted at study sites in urban settings, 16 were in suburban/peri-urban and only one study33 assessed VOT in the rural context. Of the 55 studies from which a country and income level could be inferred, 33/55 (60%) of the studies were from high-income countries, 8/55 (15%) were from upper-middle-income and middle-income countries, and 14/55 (25%) were from LMIC. Most high-income studies came from the USA (n=25, Supplementary Figure 1), which has a low TB incidence of 2.5 cases per 100,00077.
Intervention Types
Of the 47 primary research studies, the majority (n=29) were single-arm intervention studies of VOT with no comparison group. A minority of studies (n=15) were VOT versus DOT head-to-head comparisons, and the remaining three were VOT compared with other adherence methods such as SMS and medication monitors51, comparison of two different VOT apps18, and one study examining VOT in a paediatric population31. Four studies (4/66, 8%)9,36,55,57 were Randomised Control Trials (RCT) and, of the five systematic reviews, two4,71 had an accompanying meta-analysis. One study26 specifically evaluated VOT for supporting people with MDR-TB. No studies were identified that assessed VOT interventions amongst pregnant women or specifically amongst people with TB/HIV co-infection.
A Comprehensive Summary of VOT Applications
In the 66 records identified, a wide variety of applications and technologies were mentioned. Of the 20 applications identified, 12/20 (60%), including the top five most cited or used, were developed in the USA. The only VOT application developed in an LMIC context was NIMCURE from Nigeria, which has the highest TB burden in Africa accounting for 4.6% of the global TB cases78. Supplementary Table 1 summarises the applications’ characteristics, costs, and which records cited or used these.
Critical Appraisal using CCAT
Across the primary studies and review-type studies where the CCAT was applicable, the range of scores was from 21 (52.5%) to 39 (97.5%) out of 40, with a mean score of 32.38 (81%). This meant that all studies were rated as moderate to high quality on the CCAT scoring system. See Supplementary Table 2 for the disaggregation of CCAT scores attained.
Feasibility
A total of 43/66 (65%) records reported on assessments of the feasibility of VOT as a modality to measure TB adherence. Of these, 35 were primary studies, five were review-type studies and three were grey literature documents. All studies reported that VOT was feasible regardless of urbanicity (although most were conducted in urban/peri-urban settings), country income level or population context. However, the most frequently reported challenges to feasibility were lack of or unreliable internet coverage5,25,26,28,36,39,42,48,50,56,57,61,75, low quality of videos or incomplete dose verification17,26,28,34,35,40–42,60,70 and other technical issues including battery problems18,22,25,28,31,33,49,50,58.
Studies identified the need to loan a VOT-compatible smartphone to people with TB33,34,44,50 and consider the cost of packages of mobile phone data5. One study53 found that prior ownership of a smartphone was not associated with the ability to learn how to use VOT. Potential lack of rapport between HCWs and people with TB was described5,35,62 and challenges to adherence including not attending scheduled VOT appointments or being lost to follow-up were perceived to be similar to standard DOT25,26,28,33.
One retrospective study in Baltimore (urban), USA46 reported usage of VOT during the COVID-19 pandemic when DOT was not possible. It highlighted age as the main barrier to the use of VOT, with older participants finding the technology more challenging. Two studies23,52 also reported that VOT uptake, was more common in younger people. Fewer than 10% of participants in Guo et al.37 experienced issues with uploading videos for VOT and Garfein et al.32 reported that healthcare providers were able to verify most VOT-delivered doses. Holzman et al.40 showed that VOT was utilised successfully when participants travelled to another country, which the authors interpreted as potentially facilitating increased acceptability of VOT. Ravenscroft et al.55 highlighted that people with TB using VOT were more likely to report side effects than people with TB using DOT.
VOT was found to be technically feasible in the conflict setting of Syria63 but its utility was limited by intermittent supply of TB medications. Donahue et al.31 found at a military health facility for families of service members found that VOT was feasible in a paediatric population with parental support. A WHO report10 called “Digital health for the end TB strategy: An Agenda for action” considered that VOT could become more feasible as coverage of mobile smartphones with internet capability increased.
In its guidance on TB control in Europe, the ECDC scientific panel deemed that VOT was “Likely” feasible to use for vulnerable and hard-to-reach populations74.
Acceptability
A total of 44/66 (66%) records, mostly primary research studies, evaluated and reported on the acceptability of VOT. Except for a single study in the Philippines26, in which uptake of VOT was low (36%), all found VOT acceptable to people with TB and healthcare providers. A preference amongst people with TB for VOT over DOT was reported to relate to increased convenience, time-saving, and flexibility22–25,32–34,36,37,40–42,48,54. Amongst healthcare workers, two studies from China and The Philippines, reported a preference for VOT over DOT26,37. In studies which measured satisfaction levels amongst people with TB using VOT versus people with TB using DOT, people using VOT reported higher levels of satisfaction27,55,72.
Both people with TB and healthcare workers or providers raised privacy, security, and confidentiality as potential concerns with VOT across several studies 5,33,34,36,41,47,48,50,57,58. Specifically, Garfein et al.5 identified cultural concerns of videos of females with TB being observed by male care providers in certain countries or contexts. However, this was balanced by studies reporting that both people with TB and HCWs perceived VOT to be more confidential than DOT17,22,32,34,41,72. Rabinovich et al.’s concept study53 stated that although clients were receptive to the prospect of a mobile application for VOT purposes, there were concerns surrounding usability of the technology, especially for people with low literacy or who were illiterate.
In Vietnam, Nguyen et al.50 noted the most common reason (34.2%) for unwillingness to engage in VOT was not wanting to use a smartphone, but this was not mirrored by other studies. In other studies, people with TB reported appreciated ad hoc communication offered by VOT39,41 and nurses valued the professional development gained from IT training for VOT.
Costs
A total of 20/66 (33%) records, including 15 primary studies, examined costs associated with VOT. A further nine studies commented subjectively on the cost-saving attributes of VOT but did not conduct formal costing analyses. Most studies reported that, compared to healthcare facility-based or community-based DOT, VOT was associated with cost savings for people with TB, the health system, or both. There were, however, two exceptions: Asay et al.19 evaluated three TB programs offering VOT and found that, in Rhode Island, USA, a high-income context, VOT costs were not different from community-based DOT. This may have related to power because the same study suggested costs to people with TB and the health system were lower with VOT in larger cities (and cohorts) including in New York City and San Francisco. In a systematic review, Wong et al.72 found that, in the context of tuberculosis infection, SMS-reminder technology was the most cost-effective method for promoting adherence to TB preventive therapy, quoting a cost-analysis simulation study51, based in Brazil, a middle-income, high TB and TB/HIV country context.
Cost-saving attributes of VOT over DOT were due to reduced travel costs and reduced time spent observing doses in-person, with studies commenting specifically on personnel (staff) costs5,9,17,24,33,43,48,61, hours and costs including transport saved by people with TB5,37,48,55. Chuck et al.28 found that staff could observe twice the number of people with TB taking their medications per allotted appointment slot duration when using VOT compared with DOT. Asynchronous VOT was found by Lam et al45 to have lower costs to the health system than synchronous VOT but a mobile phone, software purchase, installation costs, and costs to people were not evaluated.
Effectiveness
A total of 39/66 (59%) records commented on VOT effectiveness, 29 of which were primary research studies, nine were review-type studies, and one was a grey literature article. Versus DOT, VOT was reported to be associated with better adherence across various settings8,9,21,27,28,30,33,37,46,52,55,68,71. This was often interpreted as relating to VOT, especially asynchronous VOT, being provided 7-days per week and being less affected by staffing shortages, strikes, and national holidays. Several studies reported no difference in adherence rates between VOT and DOT5,17,22,35,40,47,57,64. Perry et al.52 reported more missing doses (average 3.4% vs. 1.3%, respectively; P < 0.001) over a median period of 27 weeks but similar adherence rates (96% vs. 90%; P=0.326) in VOT vs DOT. Several studies reported high adherence rates with VOT but without comparison to a DOT control group18,24,31,32,34,41,48,50,58.
Another common measure of effectiveness was treatment completion as defined by the WHO76, which was reported as higher with VOT than DOT in various studies8,27,44. Comparable treatment completion rates with VOT versus DOT were reported in other studies4,26,28,36,47,68,71,76. No study reported treatment completion rates to be worse amongst people using VOT compared to DOT but, notably, none were specifically designed to demonstrate treatment completion inferiority or superiority. Mortality was infrequently reported but was found to be comparable in three studies4,36,76 and, in the study by Casalme et al.26 amongst people with MDR-TB, mortality was found to be lower with VOT compared with DOT. In some studies, loss to follow-up was either lower26 or the same36 with VOT versus DOT. No evidence of effectiveness to reduce other adverse TB treatment outcomes including treatment failure were identified.
Treatment success was higher amongst people with TB using VOT than DOT in one study26, but comparable between VOT and DOT in other studies36,52,55,64. Culture conversion rates for VOT were similar to DOT in three studies37,52,71. TB recurrence (i.e. return of symptoms and signs including radiological signs of clinical TB and/or microbiologically-confirmed TB) was reported in Doltu et al.30 and Guo et al.37 in the DOT control groups but not VOT groups. No other studies reported TB recurrence in either the VOT or DOT groups.
The key success, challenges, and potential solutions to VOT implementation identified above are summarised and disaggregated by country income in Table 4.
Discussion
The findings from this scoping review illustrate a lack of evidence, especially from randomised controlled trials, on the feasibility, acceptability, cost and effectiveness of VOT for people with TB in LMIC. In predominantly HIC, VOT was shown to contribute to high adherence levels and to have the potential to be more effective and cost-saving than DOT. A wide variety of VOT applications were used, most of which were developed in HICs. International consensus guidelines relating to VOT from WHO, ECDC, and CDC, were largely based on best practice and with low-grade evidence.
Availability of VOT
This scoping review was able to build on the findings of a scoping review from 201679 to update and summarise the current landscape and diversity of VOT applications used and their pricing, availability, and user interface/platform. It was identified that costs associated with VOT applications, such as user licenses, downloads, and recurrent subscription costs, are not transparent or easily available. In addition, some study trials provided smartphones for participants which may not be sustainable or suitable for upscaling within the health systems of many LMIC high TB burden settings beyond trial conditions.
Feasibility
This scoping review found that VOT was uniformly reported to be feasible in HIC but more evidence is needed from LMIC. VOT is now an established alternative to DOT in New York City, USA and London, UK9,28. Shared challenges to feasibility were identified that commonly related to technical aspects such as internet access, submissions of poor-quality videos, and initial problems with navigating the VOT applications, but most studies were able to overcome these without significant loss to follow-up reported. Personal access to a smartphone or loan of a smartphone to participants by the study was an accessibility issue raised11,23. For TB programmes to sustain VOT delivery, a pre-intervention baseline analysis of the use of smartphones and network coverage and consideration of underserved groups, including those without access, extremely impoverished, or with literacy and digital literacy issues, is essential to ensure equitable delivery of VOT, echoing recommendations from Peru80 and WHO75.
Acceptability
People living with TB and healthcare workers were widely receptive to VOT as an acceptable alternative to DOT. The WHO “Handbook for the use of digital technologies to support tuberculosis medication adherence”75 suggested the need to evaluate acceptability of VOT in subpopulations such as adolescent girls and women in high TB burden LMIC to ensure equitable impact. The ECDC scientific panel rated VOT as “likely acceptable” for adherence monitoring of underserved populations in Europe74. Future VOT implementations must assure participants that their privacy will be maintained and ensure data security in line with local legislative requirements, such as the UK’s Data Protection Act 2018. In addition, differentiating the process and impact outcomes of asynchronous versus synchronous VOT remains a knowledge gap.
To enhance acceptability for HCWs, VOT training should be used as an opportunity for continued professional development of IT skills. From the perspective of people with TB, it must be recognised that VOT is not a blanket solution for all and TB programmes should retain the option for DOT for those who prefer or require face-to-face interactions.
Costs
Of the minority of studies that formally collected and analysed cost data, most reported cost savings of VOT versus DOT for people with TB and the health system. The actual and proportional cost savings may vary between HIC and LMIC settings due to differential personnel, equipment, and logistics costs. For future studies, it was noted that other costs such as incentivising adherence, for example through weekly food vouchers, must also be included for accurate cost calculations. Our findings were similar to a previous scoping review67, which also found cost-savings of up to 58% for the healthcare system amongst 19 studies and in agreement with the ECDC scientific panel contribution74 that VOT was “Likely” cost-effective.
For people with TB, the most widely reported cost saving of VOT avoiding travel costs to DOT clinics, was also noted to have potential positive public health implications81. For HCWs, VOT was reported to improve time-efficiency and, in some cases, reduce their own travel costs compared to DOT.
Some important gaps in the literature relating to cost of VOT include within trial cost-effectiveness analyses, differential costs between synchronous and asynchronous VOT, and incorporating the impact of ownership, loans, or access to internet-enabled smartphone devices.
Effectiveness
The overarching evidence from diverse studies including early trials and post-implementation evaluations suggests that treatment outcomes in VOT are likely to be at least non-inferior to DOT. Other outcomes including treatment completion, bacteriological resolution, and mortality rate were similar to standard DOT. In line with these findings, WHO previously concluded that VOT was at least non-inferior to DOT in terms of TB treatment completion and mortality76. However, it is clear that large-scale, randomised-controlled trials in diverse settings, especially in LMIC or with vulnerable populations including those with MDR-TB, are required.
Strengths & Limitations
This scoping review has updated, consolidated and synthesised the existing evidence base on the use of VOT – including a novel table summarising the VOT applications available - to support people with TB globally. The methods are repeatable and the quality scoring using CCAT is transparent.
The review had several limitations. First, reviewers were not blinded, risking bias, and the search criteria did not include studies prior to 1st January 2000. However, the subsequent snowballing of citations did not find relevant studies earlier than this date. We also found multiple international clinical trial protocols for VOT evaluation on trials registration sites that have yet to publish their results. Second, several studies acknowledged selection bias in their recruitment with few involving randomisation, which limits their generalizability and warrants caution in the interpretation of their findings. Third, there was limited evidence evaluating forms of VOT such as synchronous versus asynchronous, the platforms or applications used to implement VOT, and vulnerable, underserved groups were neglected with only one study of VOT in children and none focused on pregnant women or people with TB and HIV or other comorbidities. These are notable gaps in the literature and understanding how VOT could be adapted for these populations is crucial for a comprehensive TB programme service delivery.
Research Recommendations
There is significant potential for future research to move the field of VOT for TB forward, especially in high TB burden LMIC. Randomised-controlled trials including those with multi-arm multi-stage or hybrid effectiveness-implementation designs and incorporating distributional or extended cost-effectiveness analyses and recognised WHO TB Patient Cost Survey methods77 could be of great value to evaluate not only effectiveness but also feasibility, acceptability, cost-effectiveness and equity of VOT. However, RCTs can be expensive and time-consuming and, programmatically, other studies or implementation projects including the use of quasi-experimental designs or interrupted time-series analysis may be more suitable.
Wider research including ecological studies and secondary analysis of existing household survey data, including data on access to phones and internet, could examine how increased penetrance of smartphone coverage and usage in LMIC could contribute to VOT being integrated within standard of care. Moreover, there has been minimal exploration of sociocultural factors associated with mobile phone usage and ownership, particularly in LMIC where there may be a gender differential in household-level economic agency. Understanding such sociocultural factors can impact VOT feasibility and hence be crucial for optimising its effectiveness. Future studies implementing and evaluating VOT would benefit from considerations of equity within their analyses, including disaggregating data by gender, urban versus rural location, socioeconomic position, educational level, literacy, and digital literacy.
Finally, broader potentials of internet-enabled smartphone technology in the future could be, alongside VOT, screening for TB in households, for example via acoustic cough analysis,82 monitoring TB preventive therapy adherence and completion, reviewing symptoms of chronic respiratory diseases in people with suspected TB but no formal diagnosis, and adjunctive features to monitor side-effects over the course of a treatment regimen.
Conclusion
The COVID-19 pandemic has accelerated acceptance of digital health technologies, their implementation, and utility. This scoping review found that VOT was reported to be a feasible, acceptable, and effective alternative to DOT, which was likely cost-saving to people with TB and health systems in HIC. More evidence is needed to inform its implementation and potential scale-up in LMICs with high TB burden.
Data Availability
The data are available from the corresponding author (email address) upon reasonable request.
Contributions
An Du Thinh (ADT): Conceptualization, Methodology, Investigation, Data Curation, Formal analysis, Writing - Original Draft, Review & Editing, Visualization
Eleanor Morgan (EM): Conceptualization, Methodology, Investigation, Data Curation, Formal analysis, Writing – supported Original Daft, Review & Editing, Visualization Kassia Pereira (KP): Conceptualization, Methodology, Investigation, Data Curation, Formal analysis, Writing - Review & Editing, Visualization
Celso Khosa (CK): Conceptualization, Methodology, Investigation, Formal analysis, Writing - Review & Editing, Visualization
Tom Wingfield (TW): Conceptualization, Methodology, Investigation, Formal analysis, Writing - Review & Editing, Visualization
All authors read and approved the final manuscript.
Ethical Considerations
There were no ethical issues or risk of harm to patients identified. Ethical approval exemption was sought and granted by LSTM. All the resources used were based on published research with previously anonymised participant demographics and outcomes. This study was nested within the larger “SAFEST-1 MDR-TB” programme of research, which includes an implementation study of VOT for people with MDR-TB in Mozambique. SAFEST-1 MDR-TB was approved by Research Ethics Committees at the Liverpool School of Tropical Medicine, UK (23-008) and the Comité Institucional de Ética do Instituto Nacional de Saude, Mozambique (148/CIE-INS/2023, 15th of November, 2023).
Conflicts of Interest & Funding Declaration
There were no conflicts of interest declared. ADT and CK and TW are affiliated with The Liverpool School of Tropical Medicine (LSTM), UK. KP and CK are affiliated with Instituto Nacional de Saúde (INS), Mozambique. CK is affiliated to Faculdade de Medicina, Eduardo Mondlane University, Mozambique and EM is affiliated with The Royal Liverpool University Hospital, UK. This scoping review has not sought or received any specific funding. However, it does form an output of a part of a larger study for the “User and Provider Acceptability and Feasibility of Video Observed Therapy for Multi-Drug Resistant Tuberculosis in Mozambique (SAFEST-1 MDR-TB)” for which funding of £30,000 was granted and the grant number is MRF-131-0006-RG-KHOS-C0942 (Medical Research Foundation, 2023).
TW is supported by grants from the Wellcome Trust, UK (209075/Z/17/Z), the Department of Health and Social Care (DHSC), the Foreign, Commonwealth & Development Office (FCDO), the Medical Research Council (MRC) and Wellcome, UK. Medical Research Council, Department for International Development, and Wellcome Trust (Joint Global Health Trials, MR/V004832/1), Medical Research Council (Public Health Intervention Development “PHIND” Award, MR/Y503216/1), and a Medical Research Foundation Meade Collaboration Grant in Epidemiology.
Availability of data and materials
The data are available from the corresponding author (email address) upon reasonable request.
Appendix/Supplemental Materials
An example of the MeSH (Medical Subject Headings) search terms used were: (TI (VOT OR (video AND observed AND therapy) OR VST OR (video AND support AND treatment) OR vDOT OR eDOT)) AND (TI (TB OR tuberculosis)) OR (AB (VOT OR (video AND observed AND therapy) OR VST OR (video AND support AND treatment) OR vDOT OR eDOT)) AND (AB (TB OR tuberculosis)). These MeSH terms were piloted and refined between team members ADT, EM, and KP.
Abbreviations and Glossary
- ADT
- An Du Thinh
- AMR
- Antimicrobial resistance
- CCAT
- Crowe Critical Appraisal Tool
- CDC
- Centers for Disease Control and Prevention; American public health agency
- CI
- Confidence Interval
- CK
- Celso Khosa
- Client
- Person living with TB; a less stigmatising term than “TB patient”
- CXR
- Chest x-ray
- DOT
- Direct Observed Therapy; commonly associated with in-person adherence monitoring for TB treatment
- DS-TB
- drug-sensitive TB
- ECDC
- European Centre for Disease Prevention and Control - the European public health agency
- eDOT
- electronic-Direct Observed Therapy; VOT in a different name
- EM
- Eleanor Morgan
- FGD
- Focus Group Discussions – structured group interviews to collect qualitative data
- GRADE
- Grading of Recommendations, Assessment, Development, and Evaluations framework for evaluating research evidence summaries
- HCW
- Healthcare Worker
- IGRA
- Interferon-gamma release assay
- INS
- Instituto Nacional de Saúde
- JBI
- Joanna Briggs Institute; consensus framework for conducting Scoping Reviews
- KP
- Kassia Pereira
- LMIC
- Lower Middle Income Country as determined by The World Bank classification
- LSTM
- Liverpool School of Tropical Medicine
- LTBI
- Latent Tuberculosis Infection
- MDR-TB
- Multidrug Resistant Tuberculosis
- MTB
- Mycobacterium tuberculosis
- NHS
- National Health Service
- NTP
- National Tuberculosis Programme
- PRISMA
- Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- RCT
- Randomised Control Trial
- RR
- Relative Risk
- SAT
- Self-Administered Therapy; TB treatments taken unobserved or monitored by healthcare professionals
- ScR
- Scoping Review; as in PRISMA-ScR
- SDG
- Sustainable Development Goals as set by the WHO/UN
- SMS
- Short Message/Messaging Service
- TB
- Tuberculosis
- TST
- Tuberculin skin test
- TW
- Tom Wingfield
- vDOT
- virtual/video-Directed Observed Therapy; VOT in a different name
- VOT
- Video Observed Therapy; also known as Video-Supported Treatment, electronic-Directly Observed Therapy and virtual/video-Directly Observed Therapy
- VST
- Video-Supported Treatment; VOT in a different name
- WHO
- World Health Organisation
- UKHSA
- United Kingdom Health Security Agency; agency formerly known as Public Health England (PHE)