iPads for tramps – good news for London

By Mike Head

So cases of tuberculosis in the UK are remaining fairly static, but the proportion of cases that are to some extent resistant to treatment are increasing. This is not good news, as single drug resistance can be superseded by multi-drug resistance (MRD-TB), which can in turn also be trumped by the especially problematic problem of  extremely drug-resistant tuberculosis (XDR-TB). Cases with some form of resistance can take 18 months (up from 6 months) to treat in even the most compliant of patients. When you consider that many of the resistant cases are seen in the so-called ‘hard to reach groups’, then one can imagine that compliance with treatment becomes a real issue. To clarify- previous research has suggested that ‘hard to reach groups’ will essentially include prisoners, homeless, and drug-users (phd anyone?).

Within London, the Find and Treat team do excellent work in taking diagnostics to the homeless. They have an x-ray van that goes into prisons, hostels and any other hot-spot for high risk groups to do on-the-spot chest x-rays.  This pro-active service is demonstrably cost-effective and useful. The main problem thereafter is – how to encourage further agreement amongst individuals who are notorious for poor compliance with taking treatments and turning up for appointments. Since even a straightforward case of active tuberculosis requires a 6 month course of treatment, what can be done to encourage the homeless to stay the course? Directly Observed Therapy (DOTS) is one option, where the patient comes into a clinic and is actually watched taking their tablets, thus compliance can be measured. Not an ideal solution though, as it’s labour-intensive and time-consuming, so what else can be done?

Give them all iPads.

Thanks very much, good night.

What? You demand an explanation? You are persistent. Okay then, listen up. I’m afraid I only have anecdotal evidence here, taken from conversations with colleagues involved in the Find and Treat programme and also a presentation by one of the team at this conference (Vanya Gant presentationat 11:50am).

So, amongst a small cohort of homeless people, colleagues associated with the Find and Treat programme gave them iPads. Stop the sniggering at the back – that’s what they did. On the tablet was a registered Skype account. The homeless person stares at the iPad and asks “what’s the catch?”. All they have to do is log on once a day, open up Skype and have a quick chat on the webcam with a healthcare professional at the other end. The homeless person takes the tablets on screen (so this would be VOT, Video Observed Therapy), the call ends and it’s same time tomorrow please. At the end of the treatment programme, the patient gets to keep the iPad.

So how many folks absconded with their shiny piece of technology? Surely they sold them for drugs? Surely there was an increase in violent crime as the tablet changed hands more often than the daily-ingested tablets?

Actually, that’ll be a ‘none’ to the first question, and ‘nope’ to questions 2 and 3 there. Compliance was high and the pilot study was very successful.

As far as I am aware, this work has not been published in any journal yet. But bearing in mind a case of multi-drug resistant tuberculosis can cost £80k-120k, an investment of a  computer costing a few hundred pounds is quite possibly a no-brainer. Even if it does fly in the face of logic, and even if the Conservative party do insist that the poorest sections of society have brought it all on themselves and don’t deserve benefits, let alone technology that only a minority of their own party members possess. But it is these sort of novel (and even brave?) incentives that we need to be considering in order to increase compliance with treatments, reduce transmissions, and ease the burden of drug-resistance.

This post was written on a Dell laptop. I took two paracetamol earlier on today for a slight headache. Other computer products and brands are available.

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0 Responses to iPads for tramps – good news for London

  1. Are prisoners really a “hard to reach group”? If so, I am horrified; how could any group be easier to reach if we put our minds to it?

    I had naïvely imagined that the one thing prison actually did, was look after the physical health of its inmates, and that the reason prisons are public health hazards was prisoner-to-prisoner contagion, rather than simple lack of attention.

  2. Mike Head says:

    Paul, the term ‘hard to reach’ is not an ideal one, certainly. In the case of prisoners, the vast majority of the prison population are in for very short sentences, then get released and are easily lost to the healthcare system.

    And even in prison, whilst we know where they are, getting healthcare in to screen and treat them effectively is not so easy. There is a chronic lack of staff and infrastructure in prisons, and no real will in the media or politicians to improve healthcare access for this (understandably) unpopular group of people.

  3. So, Mike, when we send people to prison, then as well as losing them their jobs, making them less employable in future, inducing clinical depression, and exposing them to the assaults and importunities of other prisoners, we expose them to physical health risks that they are going to spread when they get out, and don’t even monitor these properly?

    If so, then sympathy aside, the cost TO THE REST OF US of our bloated prison population is even higher than I had imagined.

  4. Hard to reach, IME, tends to mean groups that aren’t all that motivated to take part in research as well as populations that are difficult to track and keep in touch with.

    A common confounder in sampling imprisoned populations is that they can be more willing to help of they feel it will look good for them (at parole hearings) and less willing if there is no benefit to them.

    That and prisoners have actual gatekeepers controlling access to research!

  5. Mike Head says:

    EP – yeah ‘hard to reach’ is a somewhat flexible term. As said before, I personally don’t like it a huge amount, but I suppose it’s fairly memorable and might focus minds a little.

    Obviously in terms of the ‘phd’ population, prisoners will often be homeless before and after their time at Her Majesty’s pleasure, and often be drug-users too. A lot of overlap in that group, but it’s a high burden sector for several diseases, and as mentioned by Paul B, it’s a high cost to the taxpayer in trying to get hold of, and treat these people.

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