Digital adherence technology to improve medication adherence in tuberculosis patients: a systematic review and meta-analysis randomized control trials

Medication adherence is critical for successful tuberculosis (TB) treatment, yet non-adherence remains a major barrier to TB control globally. Digital adherence technologies (DAT) have emerged as promising tools to support adherence, but their effectiveness remains variably reported across settings and intervention types. To evaluate the effectiveness of DAT compared to directly observed therapy (DOT) in improving TB medication adherence through a systematic review and meta-analysis of randomized controlled trials (RCTs). A comprehensive literature search was conducted across PubMed, Scopus, EBSCO, and ScienceDirect from inception through November 7, 2024. RCTs comparing DAT (e.g., SMS reminders, video-observed therapy [VOT], medication event reminder monitors [MERM], biometric monitoring systems [BMS], ingestion sensors [IS]) with DOT were included. Study selection, data extraction, and quality appraisal were performed independently by multiple reviewers. Meta-analyses were conducted using a random-effects model, with subgroup and sensitivity analyses. This review followed the PRISMA 2020 reporting guidelines. Nineteen RCTs involving over 10,000 TB patients were included. Overall, DAT significantly improved medication adherence compared to DOT, with a pooled odds ratio (OR) of 2.853 (95% CI: 2.144-3.796; p < 0.001). Subgroup analyses indicated that VOT, MERM, and SMS reminder were consistently effective, while the highest effect sizes were seen in IS and BMS, albeit with wider confidence intervals. Effectiveness varied by country income level: DAT were more effective in high- and upper-middle-income countries, while findings in lower-income settings remained inconclusive, partly due to the limited number of studies. Sensitivity analysis confirmed the robustness of findings, and no significant publication bias was detected (Egger's test p = 0.979). DAT are significantly more effective than DOT in improving medication adherence among TB patients. Tailored implementation strategies are needed to ensure optimal selection and integration of DATs across diverse health systems. These findings support the scaling-up of context-appropriate digital tools as part of global TB control efforts.