Implementation outcomes of tuberculosis digital adherence technologies: a scoping review using the RE-AIM framework

BackgroundDigital adherence technologies have been widely promoted as a means to improve tuberculosis medication adherence. However, uptake of these technologies has been suboptimal by both patients and health workers. Not surprisingly, studies have not demonstrated significant improvement in treatment outcomes.ObjectiveThis study aimed to optimize a well-known digital adherence technology, 99DOTS, for end user needs in Uganda. We describe the findings of the ideation phase of the human-centered design methodology to adapt 99DOTS according to a set of design principles identified in the previous inspiration phase.Methods99DOTS is a low-cost digital adherence technology wherein tuberculosis medication blister packs are encased within an envelope that reveals toll-free numbers that patients can call to report dosing. We identified 2 key areas for design and testing: (1) the envelope, including the form factor, content, and depiction of the order of pill taking; and (2) the patient call-in experience. We conducted 5 brainstorming sessions with all relevant stakeholders to generate a suite of potential prototype concepts. Senior investigators identified concepts to further develop based on feasibility and consistency with the predetermined design principles. Prototypes were revised with feedback from the entire team. The envelope and call-in experience prototypes were tested and iteratively revised through focus groups with health workers (n=52) and interviews with patients (n=7). We collected and analyzed qualitative feedback to inform each subsequent iteration.ResultsThe 5 brainstorming sessions produced 127 unique ideas that we clustered into 6 themes: rewards, customization, education, logistics, wording and imagery, and treatment countdown. We developed 16 envelope prototypes, 12 icons, and 28 audio messages for prototype testing. In the final design, we altered the pill packaging envelope by adding a front flap to conceal the pills and reduce potential stigma associated with tuberculosis. The flap was adorned with either a blank calendar or map of Uganda. The inside cover contained a personalized message from a local health worker including contact information, pictorial pill-taking instructions, and a choice of stickers to tailor education to the patient and phase of treatment. Pill-taking order was indicated with colors, chevron arrows, and small mobile phone icons. Last, the call-in experience when patients report dosing was changed to a rotating series of audio messages centered on the themes of prevention, encouragement, and reassurance that tuberculosis is curable.ConclusionsWe demonstrated the use of human-centered design as a promising tool to drive the adaptation of digital adherence technologies to better address the needs and motivations of end users. The next phase of research, known as the implementation phase in the human-centered design methodology, will investigate whether the adapted 99DOTS platform results in higher levels of engagement from patients and health workers, and ultimately improves tuberculosis treatment outcomes.

Digital adherence technologies (DATs) have emerged as an alternative to directly observed therapy (DOT) for supervisions of tuberculosis (TB) treatment. We conducted a meta-analysis of implementation feedback obtained from people with TB and health care workers (HCWs) involved in TB REACH Wave 6-funded DAT evaluation projects. Projects administered standardized post-implementation surveys based on the Capability, Opportunity, Motivation, Behavior (COM-B) model to people with TB and their health care workers. The surveys included questions on demographics and technology use, Likert scale questions to assess capability, opportunity, and motivation to use DAT and open-ended feedback. We summarized demographic and technology use data descriptively, generated pooled estimates of responses to Likert scale questions within each COM-B category for people with TB and health care workers using random effects models, and performed qualitative analysis of open-ended feedback using a modified framework analysis approach. The analysis included surveys administered to 1290 people with TB and 90 HCWs across 6 TB REACH-funded projects. People with TB and HCWs had an overall positive impression of DATs with pooled estimates between 4·0 to 4·8 out of 5 across COM-B categories. However, 44% of people with TB reported taking TB medications without reporting dosing via DATs and 23% reported missing a dose of medication. Common reasons included problems with electricity, network coverage, and technical issues with the DAT platform. DATs were overall perceived to reduce visits to clinics, decrease cost, increase social support, and decrease workload of HCWs. DATs were acceptable in a wide variety of settings. However, there were challenges related to the feasibility of using current DAT platforms. Implementation efforts should concentrate on ensuring access, anticipating, and addressing technical challenges, and minimizing additional cost to people with TB.

Implementing medicare education for medication access: A review of the literature using the RE-AIM framework.

Influenza and COVID-19 are significant vaccine-preventable causes of morbidity, mortality, and healthcare costs. Hospital-based, nurse-led models can increase vaccine uptake, yet few target adults. This study evaluates the implementation of an opportunistic patient influenza and COVID-19 vaccination program in the Central Coast Local Health District (CCLHD), led by Authorized Nurse Immunizers (ANIs). Evaluation of the ANI-led program was conducted using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. The 10-week program involved screening patients for vaccine eligibility, offering vaccinations and collecting quantitative data and qualitative feedback across the five RE-AIM domains. Of 849 patients screened alongside service encounters, 398 were vaccinated with 76% of eligible patients consenting to flu and 59% to COVID-19 vaccination. Inpatients had lower vaccination rates on admission compared to the general population and higher rates after program contact. The program was well received by patients and staff and adopted across various CCLHD settings, effectively addressing community access barriers. Opportunistic vaccination using an ANI-led model is an effective strategy to improve vaccination coverage among higher-risk patients. This evaluation demonstrates the benefits of a dedicated nurse immunizer workforce and suggests potential for broader adoption in similar healthcare settings to improve public health outcomes.

BackgroundThe RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework is a reliable tool for the translation of research to practice. This framework has been widely applied to assess the impact of individual interventions. However, RE-AIM has rarely been used to evaluate implementation interventions, especially from multi-sector partnerships. The primary purpose of this paper is to operationalize the RE-AIM approach to evaluate large, multi-sector partnerships. SCI Action Canada, a community-university partnership aimed to promote physical activity among adults with spinal cord injury, is used as an example. A secondary purpose is to provide initial data from SCI Action Canada by using this conceptualization of RE-AIM.MethodsEach RE-AIM element is operationalized for multi-sector partnerships. Specific to SCI Action Canada, seven reach calculations, four adoption rates, four effectiveness outcomes, one implementation, one organizational maintenance, and two individual maintenance outcomes are defined. The specific numerators based on SCI Action Canada activities are also listed for each of these calculations.ResultsThe results are derived from SCI Action Canada activities. SCI Action Canada’s reach ranged from 3% (end-user direct national reach) to 37% (total regional reach). Adoption rates were 15% (provincial level adoption) to 76% (regional level adoption). Implementation and organizational maintenance rates were 92% and 100%, respectively.ConclusionsWe have operationalized the RE-AIM framework for larger multi-sectoral partnerships and demonstrated its applicability to such partnerships with SCI Action Canada. Future partnerships could use RE-AIM to assess their public health impact.

Poor medication adherence may increase rates of loss to follow-up, disease relapse and drug resistance for individuals with active tuberculosis (TB). While TB programmes have historically used directly observed therapy...

Evaluating the translatability and feasibility of an intervention program has become as important as determining the effectiveness of the intervention. To evaluate the applicability of a 3-month jump-landing training program in basketball players, using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Randomized controlled trial. National and regional basketball teams. Twenty-four teams of the second highest national division and regional basketball divisions in Flanders, Belgium, were randomly assigned (1:1) to a control group and intervention group. A total of 243 athletes (control group = 129, intervention group = 114), ages 15 to 41 years, volunteered. All exercises in the intervention program followed a progressive development, emphasizing lower extremity alignment during jump-landing activities. The results of the process evaluation of the intervention program were based on the 5 dimensions of the RE-AIM framework. The injury incidence density, hazard ratios, and 95% confidence intervals were determined. The participation rate of the total sample was 100% (reach). The hazard ratio was different between the intervention group and the control group (0.40 [95% confidence interval = 0.16, 0.99]; effectiveness). Of the 12 teams in the intervention group, 8 teams (66.7%) agreed to participate in the study (adoption). Eight of the participating coaches (66.7%) felt positively about the intervention program and stated that they had implemented the training sessions of the program as intended (implementation). All coaches except 1 (87.5%) intended to continue the intervention program the next season (maintenance). Compliance of the coaches in this coach-supervised jump-landing training program was high. In addition, the program was effective in preventing lower extremity injuries.

Evaluating a Multidisciplinary Model of Care for Inherited Bone Marrow Failure and Predisposition to Hematological Malignancy

IntroductionExercise is Medicine (EIM) is an initiative that seeks to integrate physical activity assessment, prescription, and patient referral as a standard in patient care. Methods to assess this integration have lagged behind its implementation.Purpose and ObjectivesThe purpose of this work is to provide a pragmatic framework to guide health care systems in assessing the implementation and impact of EIM.Evaluation MethodsA working group of experts from health care, public health, and implementation science convened to develop an evaluation model based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. The working group aimed to provide pragmatic guidance on operationalizing EIM across the different RE-AIM dimensions based on data typically available in health care settings.ResultsThe Reach of EIM can be determined by the number and proportion of patients that were screened for physical inactivity, received brief counseling and/or a physical activity prescription, and were referred to physical activity resources. Effectiveness can be assessed through self-reported changes in physical activity, cardiometabolic biometric factors, incidence/burden of chronic disease, as well as health care utilization and costs. Adoption includes assessing the number and representativeness of health care settings that adopt any component of EIM, and Implementation involves assessing the extent to which health care teams implement EIM in their clinic. Finally, Maintenance involves assessing the long-term effectiveness (patient level) and sustained implementation (clinic level) of EIM in a given health care setting.Implications for Public HealthThe availability of a standardized, pragmatic, evaluation framework is critical in determining the impact of implementing EIM as a standard of care across health care systems.

Contextualizing the Proven Effectiveness of a Lifestyle Intervention for Type 2 Diabetes in Primary Care: A Qualitative Assessment Based on the RE-AIM Framework.

Nowadays, one of the leading widespread communicable health determinants of death globally is tuberculosis (TB), which is most prevalent in low-and middle-income nations where health systems consistently struggle with a lack of diagnostic and therapeutic resources (World Health Organization 2024). To address these issues, more digital health solutions are used, such as digital adherence technologies (DATs), video-observed therapy (VOT), artificial intelligence (AI)-enabled chest X-ray computer-aided detection (CAD), electronic surveillance, laboratory connectivity, and mobile financial incentives (Cattamanchi et al., 2021). While solutions like digital adherence technologies (DATs) and video-observed therapy (VOT) significantly enhance patient accessibility and participation in tuberculosis prevention, their efficacy in improving treatment outcomes remains variable (Subbaraman et al., 2018). The World Health Organization (WHO) authorised CAD as a triage method for tuberculosis screening, as it is as precise as radiography (Qin et al., 2021). When used in African contexts, connectivity technologies such as GxAlert reduce the time between diagnosis and the start of therapy (SystemOne, 2020). Besides, socioeconomic barriers to adherence are addressed through mobile money-based incentives, which have been investigated in TB programs in Africa (Krishnan et al., 2021). Additionally, long-term effectiveness, equity, compatibility, and coordination and regulation of digital health technologies remain enduring issues (Wingfield et al., 2020). The analysis highlights crucial perspectives and insights from current research, demonstrating the primary role of digital health applications in tuberculosis prevention in facilitating patient-focused, comprehensive care, distinct from alternatives to fundamental TB services (World Health Organization, 2024).

BackgroundAdherence to tuberculosis(TB) preventive treatment (TPT) remains a significant challenge in high-TB burden countries like Bangladesh, where approximately 44 million people are infected with latent tuberculosis.Methods/DesignThis study protocol describes a mixed-methods observational study to evaluate “iDOTS,” a locally developed digital adherence technology adapted from 99DOTS, for monitoring and improving TPT adherence among adult household contacts of bacteriologically confirmed pulmonary TB patients. The study will be conducted in two districts in Bangladesh with similar geographical and societal characteristics, with Narsingdi as the intervention site and Manikganj as the control site. Applying the Unified Theory of Acceptance and Use of Technology (UTAUT), we will assess technology acceptance, implementation challenges, and effectiveness through quantitative and qualitative approaches. The mixed method approach will compare TPT adherence between iDOTS users and non-users, and will explore user experiences and attitudes among healthcare providers and patients. Adherence will be verified through a combination of digital records, self-reports, and random isoniazid urine testing.DiscussionWith an estimated sample size of 422 patients and 77 healthcare providers, this study aims to generate evidence that if digital adherence technologies can strengthen TPT implementation in resource-limited settings. The findings will address critical gaps in the TPT cascade and inform strategies for scaling up TPT nationally, ultimately supporting global efforts to reduce the TB disease burden through effective preventive measures.Trial registration'Not applicable'.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12889-025-24368-7.

Latinos bear a disproportionate burden of the dual pandemic of obesity and diabetes. However, successful interventions addressing this disparity through primary care are lacking. To address this gap, the 5-year Vida Sana (Healthy Life) study tests a culturally adapted and technology-enhanced group-based Diabetes Prevention Program intervention in a randomized controlled trial with overweight/obese Latino adults who have metabolic syndrome and/or pre-diabetes. Eligible, consenting patients (n=186) from a large community-based multispecialty group practice in Northern California will be randomly assigned to receive the culturally-adapted intervention or usual care. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework guided the planned evaluations. The primary aim is to determine the effectiveness of the intervention (the “E” in RE-AIM). We hypothesize that the intervention will lead to a greater mean reduction in weight at 24months (primary endpoint) vs. usual care. Secondary outcomes will include measures of cardiometabolic risk factors (e.g., blood pressure), psychosocial well-being (e.g., health-related quality of life), and behavior change (e.g., physical activity). The secondary aim is to evaluate the other RE-AIM dimensions using mixed methods: reach (e.g., participation rate of the target population), adoption (e.g., participating clinic and provider characteristics), implementation (e.g., intervention fidelity), and maintenance (e.g., sustainability in the practice setting). These findings have real word applicability with value to clinicians, patients, and other decision makers considering effective diabetes prevention programs for primary care that would support the millions of Latino adults who experience a disproportionate burden of diabetes.Trial registration: NCT02459691.

The physical activity levels of children in Australia are critically low and correlate with reduced academic achievement and poor health outcomes. Schools provide an ideal setting for physical activity interventions to help children move more. Instead of targeting in-service teachers, this study embedded an evidence-based active pedagogy program called Transform-Ed! into pre-service teacher education. Pre/post surveys and post-program interviews and focus group discussions were conducted with key stakeholders (n = 5), lecturers (n = 6), and pre-service teachers (n = 274) involved with the 12-week program. The design, implementation, and evaluation of the study were systematically guided by all five dimensions of Glasgow and colleagues’ RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Linear mixed models, descriptive analysis and a framework approach were used to analyse the data. Significant improvements were observed in pre-service teachers’ willingness, confidence, and competence to implement physically active pedagogic strategies following the intervention. Pre-service teacher perceived effectiveness of such strategies on student outcomes also significantly increased and perceived barriers decreased. High adherence was consistently reported and the program was maintained after completion of the implementation trial by all lecturers. Four key themes spanning multiple dimensions and participant levels informed recommendations for program scalability: an “inter-systemic approach”, a “co-design” approach, “embedded in professional practice”, and “evidence of impact” on teacher practice. Anchored in real-world settings and tethered by implementation science, Transform-Ed! could have the potential to advance the teaching capability of teachers, and transform the learning experience and physical and academic outcomes of primary school students.

Outdoor play has been described as essential for healthy childhood development. Lack of safety is one barrier to children participating in outdoor play. Play Streets are an intervention to help increase outdoor play by temporarily closing public streets (closures are recurring or episodic) to traffic, creating a safe place for active play. This systematic grey literature review aimed to examine and describe what is known about implementing Play Streets using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, which is widely used in implementation research. A systematic search for and review of nonacademic, or grey, literature was conducted using Academic Search Complete, Google Scholar, and a general Google search. Included literature was published in English, through December 2017, in nonacademic sources (ie, organizational/grant/municipal reports, newspapers, conference presentations, previous intervention advertisement materials, Web-based articles) or found in reference lists of academic articles about Play Streets, Pop-up Parks, or Open Streets/Ciclovías with a Play Street component. Resources were selected that documented Play Streets, which are defined as recurring or episodic temporary street closures to traffic that provide the public with a no-cost, safe space to actively play and be physically active. These approaches are designed primarily for youth and may include various marked play areas, loose equipment, and/or group activities. RE-AIM measures guided data extraction. Of the 36 articles composing the final sample, 100% reported on implementation, although the level of detail varied. Only 14 of 36 articles reported measures of effectiveness; limited information was provided for other RE-AIM components. In the grey literature, there are several inconsistencies in how the implementation of Play Streets is reported and level of detail. Specific details regarding implementing and evaluating Play Streets are needed to support widespread replication.