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Basile FW, Sweeney S, Singh MP, Bijker EM, Cohen T, Menzies NA, Vassall A, Indravudh P. Uncertainty in tuberculosis clinical decision-making: An umbrella review with systematic methods and thematic analysis. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003429. [PMID: 39042611 PMCID: PMC11265660 DOI: 10.1371/journal.pgph.0003429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 06/12/2024] [Indexed: 07/25/2024]
Abstract
Tuberculosis is a major infectious disease worldwide, but currently available diagnostics have suboptimal accuracy, particularly in patients unable to expectorate, and are often unavailable at the point-of-care in resource-limited settings. Test/treatment decision are, therefore, often made on clinical grounds. We hypothesized that contextual factors beyond disease probability may influence clinical decisions about when to test and when to treat for tuberculosis. This umbrella review aimed to identify such factors, and to develop a framework for uncertainty in tuberculosis clinical decision-making. Systematic reviews were searched in seven databases (MEDLINE, CINAHL Complete, Embase, Scopus, Cochrane, PROSPERO, Epistemonikos) using predetermined search criteria. Findings were classified as barriers and facilitators for testing or treatment decisions, and thematically analysed based on a multi-level model of uncertainty in health care. We included 27 reviews. Study designs and primary aims were heterogeneous, with seven meta-analyses and three qualitative evidence syntheses. Facilitators for decisions to test included providers' advanced professional qualification and confidence in tests results, availability of automated diagnostics with quick turnaround times. Common barriers for requesting a diagnostic test included: poor provider tuberculosis knowledge, fear of acquiring tuberculosis through respiratory sampling, scarcity of healthcare resources, and complexity of specimen collection. Facilitators for empiric treatment included patients' young age, severe sickness, and test inaccessibility. Main barriers to treatment included communication obstacles, providers' high confidence in negative test results (irrespective of negative predictive value). Multiple sources of uncertainty were identified at the patient, provider, diagnostic test, and healthcare system levels. Complex determinants of uncertainty influenced decision-making. This could result in delayed or missed diagnosis and treatment opportunities. It is important to understand the variability associated with patient-provider clinical encounters and healthcare settings, clinicians' attitudes, and experiences, as well as diagnostic test characteristics, to improve clinical practices, and allow an impactful introduction of novel diagnostics.
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Affiliation(s)
- Francesca Wanda Basile
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Maninder Pal Singh
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Else Margreet Bijker
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Department of Paediatrics, Maastricht University Medical Centre, MosaKids Children’s Hospital, Maastricht, the Netherlands
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Nicolas A. Menzies
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Pitchaya Indravudh
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Pape S, Karki SJ, Heinsohn T, Brandes I, Dierks ML, Lange B. Tuberculosis case fatality is higher in male than female patients in Europe: a systematic review and meta-analysis. Infection 2024:10.1007/s15010-024-02206-z. [PMID: 38521839 DOI: 10.1007/s15010-024-02206-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/02/2024] [Indexed: 03/25/2024]
Abstract
PURPOSE Epidemiological TB data indicate differences in infection prevalence, progression rates, and clinical disease incidence between sexes. In contrast, evidence on sex-specific differential (post) TB case fatality in Europe has not been synthesized systematically. METHODS We searched electronic databases and grey literature up to December 2020 for studies reporting sex-stratified TB death data for Europe. The JBI critical appraisal tools served for bias risk assessment and subgroup analyses for studying heterogeneity. Random-effects models meta-analyses enabled estimating pooled relative risks of sex-associated TB fatality. Considering associations of comorbidities and risk factors on fatality differences, we applied relative risk meta-regression. RESULTS Based on 17,400 records screened, 117 studies entered quantitative analyses. Seventy-five studies providing absolute participant data with moderate quality and limited sex stratification reported 33 to 235,000 TB cases and 7 to 27,108 deaths. The pooled male-to-female TB fatality risk ratio was 1.4 [1.3-1.5]. Heterogeneity was high between studies and subgroups. Study time, concurrent comorbidities (e.g., HIV, diabetes, cancers), and mean participant ages showed no effect modification. We identified higher male TB fatality in studies with higher homelessness (coefficient 3.18, 95% CI [-0.59 to 6.94], p-value 0.10) and lower migrants proportion (coefficient - 0.24, 95% CI [- 0.5 to 0.04], p-value 0.09). CONCLUSION We found 30-50% higher TB case fatality for males in Europe. Except for homelessness, migration, and a trend for some comorbidities, assessing effect modification could not reduce our meta-analysis' high heterogeneity. Public health authorities should take heed of this higher risk of dying in male patients' treatment services.
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Affiliation(s)
- Stephanie Pape
- Institute for Epidemiology, Social Medicine and Health Systems, Hannover Medical School, Hannover, Germany.
- Department of Epidemiology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany.
| | - Sudip Jung Karki
- Department of Epidemiology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
- Faculty of Medicine, Université Toulouse III Paul Sabatier, Toulouse, Occitanie, France
| | - Torben Heinsohn
- Department of Epidemiology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
| | - Iris Brandes
- Institute for Epidemiology, Social Medicine and Health Systems, Hannover Medical School, Hannover, Germany
| | - Marie-Luise Dierks
- Institute for Epidemiology, Social Medicine and Health Systems, Hannover Medical School, Hannover, Germany
| | - Berit Lange
- Department of Epidemiology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
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3
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Teo AKJ, Singh SR, Prem K, Hsu LY, Yi S. Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis. Respir Res 2021; 22:251. [PMID: 34556113 PMCID: PMC8459488 DOI: 10.1186/s12931-021-01841-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 09/08/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Thirty countries with the highest tuberculosis (TB) burden bear 87% of the world's TB cases. Delayed diagnosis and treatment are detrimental to TB prognosis and sustain TB transmission in the community, making TB elimination a great challenge, especially in these countries. Our objective was to elucidate the duration and determinants of delayed diagnosis and treatment of pulmonary TB in high TB-burden countries. METHODS We conducted a systematic review and meta-analysis of quantitative and qualitative studies by searching four databases for literature published between 2008 and 2018 following PRISMA guidelines. We performed a narrative synthesis of the covariates significantly associated with patient, health system, treatment, and total delays. The pooled median duration of delay and effect sizes of covariates were estimated using random-effects meta-analyses. We identified key qualitative themes using thematic analysis. RESULTS This review included 124 articles from 14 low- and lower-middle-income countries (LIC and LMIC) and five upper-middle-income countries (UMIC). The pooled median duration of delays (in days) were-patient delay (LIC/LMIC: 28 (95% CI 20-30); UMIC: 10 (95% CI 10-20), health system delay (LIC/LMIC: 14 (95% CI 2-28); UMIC: 4 (95% CI 2-4), and treatment delay (LIC/LMIC: 14 (95% CI 3-84); UMIC: 0 (95% CI 0-1). There was consistent evidence that being female and rural residence was associated with longer patient delay. Patient delay was also associated with other individual, interpersonal, and community risk factors such as poor TB knowledge, long chains of care-seeking through private/multiple providers, perceived stigma, financial insecurities, and poor access to healthcare. Organizational and policy factors mediated health system and treatment delays. These factors included the lack of resources and complex administrative procedures and systems at the health facilities. We identified data gaps in 11 high-burden countries. CONCLUSIONS This review presented the duration of delays and detailed the determinants of delayed TB diagnosis and treatment in high-burden countries. The gaps identified could be addressed through tailored approaches, education, and at a higher level, through health system strengthening and provision of universal health coverage to reduce delays and improve access to TB diagnosis and care. PROSPERO registration: CRD42018107237.
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Affiliation(s)
- Alvin Kuo Jing Teo
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore.
- Saw Swee Hock School of Public Health, National University of Singapore, #10-01, 12 Science Drive 2, Singapore, 117549, Singapore.
| | - Shweta R Singh
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Kiesha Prem
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Li Yang Hsu
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - Siyan Yi
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
- Center for Global Health Research, Touro University California, Vallejo, USA
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Ronchetto M, Ronchetto F. Social, cultural and political aspects concerning tuberculosis and its persistence in the world and within societies. An overview. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2019. [DOI: 10.23736/s0393-3660.18.03932-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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5
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Teo AKJ, Singh SR, Prem K, Hsu LY, Yi S. Delayed diagnosis and treatment of pulmonary tuberculosis in high-burden countries: a systematic review protocol. BMJ Open 2019; 9:e029807. [PMID: 31289094 PMCID: PMC6629411 DOI: 10.1136/bmjopen-2019-029807] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/05/2019] [Accepted: 06/12/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Countries identified to bear the highest tuberculosis (TB) incidence account for approximately 85% of the global TB burden. TB is curable, yet nearly 40% of TB cases remained undiagnosed hence delaying treatment and perpetuating transmission. This systematic review aimed to review current evidence on factors associated with delayed diagnosis and treatment of TB in the high TB-burden countries. METHODS AND ANALYSIS This systematic review will incorporate qualitative and observational study designs published between 2008 and 2018. Articles will be retrieved from major databases including PubMed, EMBASE, CINAHL and PsycINFO. Reference lists of key articles, including relevant systematic reviews and meta-analysis, will be screened for additional studies. Two independent reviewers will screen and select studies, extract data and assess the quality and risk of bias of each study. Study-specific estimates will be pooled by meta-analysis, and effect sizes will be presented as OR and their 95% CI. Levels of heterogeneity will be evaluated using chi-square statistic Q and I2. Publication bias will be assessed using forest plots and Egger's tests. Qualitative findings and sample quotes will be extracted. Textual references to the topics of interest will be retrieved and categorised using qualitative thematic analysis. We will triangulate quantitative and qualitative findings for a complete understanding of the reasons for delayed TB diagnosis and treatment. Results will be presented by geographical region. ETHICS AND DISSEMINATION This study will be conducted based on published data. This systematic review may provide insights into the reasons for delayed TB diagnosis in high-burden countries. These findings will also inform future research and key stakeholders in developing interventions to reach these undiagnosed cases effectively. Findings from this review will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42018107237.
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Affiliation(s)
- Alvin Kuo Jing Teo
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Shweta R Singh
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Kiesha Prem
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Li Yang Hsu
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Siyan Yi
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Center for Population Health Research, KHANA, Phnom Penh, Cambodia
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6
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Shewade HD, Gupta V, Satyanarayana S, Pandey P, Bajpai UN, Tripathy JP, Kathirvel S, Pandurangan S, Mohanty S, Ghule VH, Sagili KD, Prasad BM, Nath S, Singh P, Singh K, Singh R, Jayaraman G, Rajeswaran P, Srivastava BK, Biswas M, Mallick G, Bera OP, Sahai KN, Murali L, Kamble S, Deshpande M, Kumar N, Kumar S, Jaisingh AJJ, Naqvi AJ, Verma P, Ansari MS, Mishra PC, Sumesh G, Barik S, Mathew V, Lohar MRS, Gaurkhede CS, Parate G, Bale SY, Koli I, Bharadwaj AK, Venkatraman G, Sathiyanarayanan K, Lal J, Sharma AK, Rao R, Kumar AMV, Chadha SS. Patient characteristics, health seeking and delays among new sputum smear positive TB patients identified through active case finding when compared to passive case finding in India. PLoS One 2019; 14:e0213345. [PMID: 30865730 PMCID: PMC6415860 DOI: 10.1371/journal.pone.0213345] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 02/20/2019] [Indexed: 11/18/2022] Open
Abstract
Background Axshya SAMVAD is an active tuberculosis (TB) case finding (ACF) strategy under project Axshya (Axshya meaning ‘free of TB’ and SAMVAD meaning ‘conversation’) among marginalized and vulnerable populations in 285 districts of India. Objectives To compare patient characteristics, health seeking, delays in diagnosis and treatment initiation among new sputum smear positive TB patients detected through ACF and passive case finding (PCF) under the national TB programme in marginalized and vulnerable populations between March 2016 and February 2017. Methods This observational analytic study was conducted in 18 randomly sampled Axshya districts. We enrolled all TB patients detected through ACF and an equal number of randomly selected patients detected through PCF in the same settings. Data on patient characteristics, health seeking and delays were collected through record review and patient interviews (at their residence). Delays included patient level delay (from eligibility for sputum examination to first contact with any health care provider (HCP)), health system level diagnosis delay (from contact with first HCP to TB diagnosis) and treatment initiation delays (from diagnosis to treatment initiation). Total delay was the sum of patient level, health system level diagnosis delay and treatment initiation delays. Results We included 234 ACF-diagnosed and 231 PCF-diagnosed patients. When compared to PCF, ACF patients were relatively older (≥65 years, 14% versus 8%, p = 0.041), had no formal education (57% versus 36%, p<0.001), had lower monthly income per capita (median 13.1 versus 15.7 USD, p = 0.014), were more likely from rural areas (92% versus 81%, p<0.002) and residing far away from the sputum microscopy centres (more than 15 km, 24% versus 18%, p = 0.126). Fewer patients had history of significant loss of weight (68% versus 78%, p = 0.011) and sputum grade of 3+ (15% versus 21%, p = 0.060). Compared to PCF, HCP visits among ACF patients was significantly lower (median one versus two HCPs, p<0.001). ACF patients had significantly lower health system level diagnosis delay (median five versus 19 days, p = 0.008) and the association remained significant after adjusting for potential confounders. Patient level and total delays were not significantly different. Conclusion Axshya SAMVAD linked the most impoverished communities to TB care and resulted in reduction of health system level diagnosis delay.
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Affiliation(s)
- Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- * E-mail:
| | - Vivek Gupta
- All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Srinath Satyanarayana
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Prabhat Pandey
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - U. N. Bajpai
- Voluntary Health Association of India (VHAI), New Delhi, India
| | - Jaya Prasad Tripathy
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Soundappan Kathirvel
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sripriya Pandurangan
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Subrat Mohanty
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Vaibhav Haribhau Ghule
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Karuna D. Sagili
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Banuru Muralidhara Prasad
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Sudhi Nath
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Priyanka Singh
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | - Kamlesh Singh
- Catholic Health Association of India (CHAI), Telangana, India
| | - Ramesh Singh
- Voluntary Health Association of India (VHAI), New Delhi, India
| | - Gurukartick Jayaraman
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | - P. Rajeswaran
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | | | - Moumita Biswas
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Gayadhar Mallick
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Om Prakash Bera
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - K. N. Sahai
- State TB Cell, Department of Health & Family Welfare, Government of Bihar, Patna, India
| | - Lakshmi Murali
- State TB Cell, Department of Health & Family Welfare, Government of Tamil Nadu, Chennai, India
| | - Sanjeev Kamble
- State TB Cell, Health Department, Government of Maharashtra, Pune, India
| | - Madhav Deshpande
- State TB Cell, Department of Health & Family Welfare, Government of Chattisgarh, Raipur, India
| | - Naresh Kumar
- State TB Cell, Department of Health & Family Welfare, Government of Punjab, Chandigarh, India
| | - Sunil Kumar
- State TB Cell, Department of Health & Family Welfare, Government of Kerala, Thiruvananthapuram, India
| | | | - Ali Jafar Naqvi
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | - Prafulla Verma
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | | | - Prafulla C. Mishra
- Catholic Bishops’ Conference of India-Coalition for AIDS and Related Diseases (CBCI-CARD), New Delhi, India
| | - G Sumesh
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | - Sanjeeb Barik
- Emmanuel Hospital Association (EHA), New Delhi, India
| | - Vijesh Mathew
- Catholic Health Association of India (CHAI), Telangana, India
| | | | | | - Ganesh Parate
- MAMTA Health Institute for Mother and Child, New Delhi, India
| | | | - Ishwar Koli
- Catholic Health Association of India (CHAI), Telangana, India
| | | | - G. Venkatraman
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | - K. Sathiyanarayanan
- Resource Group for Education & Advocacy for Community Health (REACH), Chennai, India
| | - Jinesh Lal
- Catholic Health Association of India (CHAI), Telangana, India
| | | | - Raghuram Rao
- Central TB Division, Revised National Tuberculosis Control Programme, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Ajay M. V. Kumar
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Sarabjit Singh Chadha
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
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Sundaram N, James R, Sreynimol U, Linda P, Yoong J, Saly S, Koeut P, Eang MT, Coker R, Khan MS. A strong TB programme embedded in a developing primary healthcare system is a lose-lose situation: insights from patient and community perspectives in Cambodia. Health Policy Plan 2018; 32:i32-i42. [PMID: 29028227 DOI: 10.1093/heapol/czx079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 11/13/2022] Open
Abstract
As exemplified by the situation in Cambodia, disease specific (vertical) health programmes are often favoured when the health system is fragile. The potential of such an approach to impede strengthening of primary healthcare services has been studied from a health systems perspective in terms of access and quality of care. In this bottom-up, qualitative study we investigate patient and community member experiences of health services when a strong tuberculosis (TB) programme is embedded into a relatively underutilized primary healthcare system. We conducted six gender-stratified community focus group discussions (n = 49) and seven mixed-gender focus group discussions with TB patients (n = 45) in three provinces located in urban, peri-urban and rural areas of Cambodia. Our analysis of health-seeking behaviour and experiences for TB and TB-like illness indicates that building a strong vertical TB control programme has had numerous benefits, including awareness of typical symptoms and need to seek care early; confidence in free TB services at public facilities; and willingness to complete treatment. However, there was a clear dichotomy in experiences and behaviour with respect to care-seeking for less severe illness at primary health services, which were generally avoided owing to access barriers and perceived poor quality. The tendency to delay seeking health care until the development of severe symptoms clearly indicative of TB is a major barrier to early diagnosis and treatment of TB. Our study indicates that an imbalance in the strength of vertical and primary health services could be a lose-lose situation as this impedes improvements in health system functioning and constrains progress of vertical disease control programmes.
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Affiliation(s)
- Neisha Sundaram
- Saw Swee Hock School of Public Health, National University of Singapore, 0808 Rivergate, 97 Robertson Quay, Singapore 238257, Singapore
| | - Richard James
- Saw Swee Hock School of Public Health, National University of Singapore, 0808 Rivergate, 97 Robertson Quay, Singapore 238257, Singapore
| | - Um Sreynimol
- Celagrid - Center for Livestock and Agriculture Development, No. 5, Street 181, Phnom Penh 12306, Cambodia
| | - Pen Linda
- University of Health Science, Phnom Penh, Cambodia
| | - Joanne Yoong
- Saw Swee Hock School of Public Health, National University of Singapore, 0808 Rivergate, 97 Robertson Quay, Singapore 238257, Singapore.,Center for Economic and Social Research, University of Southern California, 635 Downey Way, VPD, Los Angeles, CA 90089, USA
| | - Saint Saly
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - Pichenda Koeut
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - Mao Tan Eang
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - Richard Coker
- Communicable Diseases Policy Research Group, London School of Hygiene and Tropical Medicine, Bangkok, Thailand.,Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Mishal S Khan
- Saw Swee Hock School of Public Health, National University of Singapore, 0808 Rivergate, 97 Robertson Quay, Singapore 238257, Singapore.,Communicable Diseases Policy Research Group, London School of Hygiene and Tropical Medicine, Bangkok, Thailand
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8
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Shewade HD, Kokane AM, Singh AR, Parmar M, Verma M, Desikan P, Khan SN, Kumar AMV. Provider reported barriers and solutions to improve testing among tuberculosis patients 'eligible for drug susceptibility test': A qualitative study from programmatic setting in India. PLoS One 2018; 13:e0196162. [PMID: 29677210 PMCID: PMC5909888 DOI: 10.1371/journal.pone.0196162] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 04/06/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In a study conducted in Bhopal district (a setting with facility for molecular drug susceptibility testing (DST)) located in central India in 2014-15, we found high levels of pre-diagnosis attrition among patients with presumptive multi drug-resistant tuberculosis (MDR-TB)-meaning TB patients who were eligible for DST, were not being tested. OBJECTIVES In this study, we explored the health care provider perspectives into barriers and suggested solutions for improving DST. METHODS This was a descriptive qualitative study. One to one interviews (n = 10) and focus group discussions (n = 2) with experienced key informants involved in programmatic management of DR-TB were conducted in April 2017. Manual descriptive thematic analysis was performed. RESULTS The key barriers reported were a) lack of or delay in identification of patients eligible for DST because of using treatment register as the source for identifying patients b) lack of assured specimen transport after patient identification and c) lack of tracking. Extra pulmonary TB patients were not getting identified as eligible for DST. Solutions suggested by the health care providers were i) generation of unique identifier at identification in designated microscopy center (DMC), immediate intimation of unique identifier to district and regular monitoring by senior TB laboratory and senior treatment supervisors of patients eligible for DST that were missed; ii) documentation of unique identifier at each step of cascade; iii) use of human carriers/couriers to transport specimen from DMCs especially in rural areas; and iv) routine entry of all presumptive extra-pulmonary TB specimen, as far as possible, in DMC laboratory register. CONCLUSION Lack of assured specimen transport and lack of accountability for tracking patient after identification and referral were the key barriers. The identification of patients eligible for DST among microbiologically confirmed TB at the time of diagnosis and among clinically confirmed TB at the time of treatment initiation is the key. Use of unique identifier at identification and its use to ensure cohort wise tracking has to be complemented with specimen transport support and prompt feedback to the DMC. The study has implications to improve detection of MDR-TB among diagnosed/notified TB patients.
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Affiliation(s)
- Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India.,International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Arun M Kokane
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Akash Ranjan Singh
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Malik Parmar
- World Health Organization, Country Office in India, New Delhi, India
| | - Manoj Verma
- State TB cell, Department of Health and Family Welfare, Bhopal, Madhya Pradesh, India
| | - Prabha Desikan
- Bhopal Memorial Hospital and Research Center, Bhopal, Madhya Pradesh, India
| | - Sheeba Naz Khan
- State TB cell, Department of Health and Family Welfare, Bhopal, Madhya Pradesh, India
| | - Ajay M V Kumar
- International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India.,International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
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Barnabishvili M, Ulrichs T, Waldherr R. Role of acceptability barriers in delayed diagnosis of Tuberculosis: Literature review from high burden countries. Acta Trop 2016; 161:106-13. [PMID: 27311390 DOI: 10.1016/j.actatropica.2016.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 06/08/2016] [Accepted: 06/10/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE Direct transmission of mutated tuberculosis (TB) strains is among major contributors to the worldwide epidemic of Drug-Resistant Tuberculosis. Expanding access to TB-services and decreasing diagnostic delays are acknowledged as potential solutions. We aimed to summarize evidence about links between health care acceptability barriers and TB diagnostic delays. Scoping and systematic review approaches were combined to determine the depth/breadth of the literature, identify gaps, and synthesize findings. METHODS Electronic data-bases, key journals, other relevant electronic sources, and references of relevant articles were selected as potential sources through a preliminary search and expertś advice. Titles and abstracts of 4046 initial records and 1796 references were screened against preliminarily developed and post-hoc inclusion/exclusion criteria. Author, year of publication, study location, study aims, overview of methods, study population, intervention type, outcomes measures and results of each included paper were extracted. Methodological quality of studies was assessed. Narrative synthesis of the study results was conducted through the thematic analysis approach. RESULTS Patients' negative expectations, doubts about quality of services/medications and burden of stigma, as well as providers' discriminative attitudes towards patients' characteristics (age, gender, ethnicity) were reported as major barriers. Scarcity and unequal distribution of the literature and lack of attention to all potential acceptability barriers were found as major gaps in the current research. CONCLUSION Overall, study findings indicate the significance of acceptability barriers' role in TB diagnostic delays. Emerging character of the field is demonstrated. Recommendations about further research directions are outlined.
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Affiliation(s)
- Maia Barnabishvili
- Berlin School of Public Health, Charité Universitätsmedizin Berlin, Seestr. 73, 13347 Berlin, Germany.
| | - Timo Ulrichs
- Berlin School of Public Health, Charité Universitätsmedizin Berlin, Seestr. 73, 13347 Berlin, Germany.
| | - Ruth Waldherr
- Berlin School of Public Health, Charité Universitätsmedizin Berlin, Seestr. 73, 13347 Berlin, Germany.
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Barnabishvili M, Ulrichs T, Waldherr R. Data on the descriptive overview and the quality assessment details of 12 qualitative research papers. Data Brief 2016; 8:1059-68. [PMID: 27508265 PMCID: PMC4969085 DOI: 10.1016/j.dib.2016.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 06/29/2016] [Accepted: 07/07/2016] [Indexed: 10/27/2022] Open
Abstract
This data article presents the supplementary material for the review paper "Role of acceptability barriers in delayed diagnosis of Tuberculosis: Literature review from high burden countries" (Barnabishvili et al., in press) [1]. General overview of 12 qualitative papers, including the details about authors, years of publication, data source locations, study objectives, overview of methods, study population characteristics, as well as the details of intervention and the outcome parameters of the papers are summarized in the first two tables included to the article. Quality assessment process of the methodological strength of 12 papers and the results of the critical appraisal are further described and summarized in the second part of the article.
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Affiliation(s)
- Maia Barnabishvili
- Berlin School of Public Health, Charité Universitätsmedizin Berlin, Seestr. 73, 13347 Berlin, Germany
| | - Timo Ulrichs
- Berlin School of Public Health, Charité Universitätsmedizin Berlin, Seestr. 73, 13347 Berlin, Germany
| | - Ruth Waldherr
- Berlin School of Public Health, Charité Universitätsmedizin Berlin, Seestr. 73, 13347 Berlin, Germany
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