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. 2017 Oct 19;12(10):e0185549.
doi: 10.1371/journal.pone.0185549. eCollection 2017.

Reaching the end of the line: Operational issues with implementing phone-based unannounced pill counts in resource-limited settings

Yael Hirsch-Moverman  1   2 , Camilla Burkot  3 , Suzue Saito  1   2 , Koen Frederix  1 , Blanche Pitt  1 , Zenebe Melaku  1 , Tsigereda Gadisa  1 , Andrea A Howard  1   2
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Reaching the end of the line: Operational issues with implementing phone-based unannounced pill counts in resource-limited settings

Yael Hirsch-Moverman et al. PLoS One. .

Abstract

Introduction: Accurate measurement of adherence is necessary to ensure that therapeutic outcomes can be attributed to the recommended treatment. Phone-based unannounced pill counts were shown to be feasible and reliable measures of adherence in developed settings; and have been further used as part of medication adherence interventions. However, it is not clear whether this method can be implemented successfully in resource-limited settings, where cellular network and mobile phone coverage may be low. Our objective is to describe operational issues surrounding the use of phone-based unannounced pill counts in Lesotho and Ethiopia.

Methods: Phone-based monthly unannounced pill counts, using an adaptation of a standardized protocol from previous US-based studies, were utilized to measure anti-TB and antiretroviral medication adherence in two implementation science studies in resource-limited settings, START (Lesotho) and ENRICH (Ethiopia).

Results: In START, 19.6% of calls were completed, with 71.9% of participants reached at least once; majority of failed call attempts were due to phones not being available (54.8%) or because participants were away from the pills (32.7%). In ENRICH, 33.5% of calls were completed, with 86.7% of participants reached at least once; the main reasons for failed call attempts were phones being switched off (31.5%), participants not answering (27.3%), participants' discomfort speaking on the phone (15.4%), and network problems (13.2%). Structural, facility-level, participant-level, and data collection challenges were encountered in these settings.

Discussion: Phone-based unannounced pill counts were found to be challenging, and response rates suboptimal. While some of these challenges were specific to local contexts, most of them are generalizable to resource-limited settings. In a research study context, a possible solution to ease operational challenges may be to focus phone-based unannounced pill count efforts on a randomly selected sample from participants who are provided with study phones and rigorously ensure that call attempts are made for these participants.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Implementation challenges of phone-based unannounced pill counts in resource-limited settings.
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