Evidence based interventions and implementation gaps in control of tuberculosis: A systematic review in low and middle-income countries with special focus on India

High stigma prevalence and associated factors among TB patients in Southern Afghanistan: A multi-center cross-sectional study

BACKGROUND

TB stigma represents a growing threat to TB care. Understanding TB stigma distribution and associating factors is crucial for effective TB control in Afghanistan.

OBJECTIVES

To profile the prevalence of TB-related stigma and its associating factors among TB patients in Southern Afghanistan.

METHODS

In this multi-center cross-sectional study, we randomly recruited 603 adult TB patients from 2 major TB treatment sites in Southern Afghanistan. A score of >8 on the Stigma Scale for Chronic Illness-8 items (SSCI-8 items) was considered as positive for TB-related stigma. We fitted a binary logistic regression model.

RESULTS

Out of the 603 TB patients included in this study, 88.3% (95%CI: 85.8-90.9%) had TB-related stigma using the SSCI-8 cutoff (>8). Being in the age group 18-40 years, rural residence, no formal education, severe perception of illness, lack of TB knowledge, and symptoms of depression had positive associations with TB stigma.

CONCLUSION

A considerable percentage (88.3%) of patients had TB stigma. We identified potential risk factors that could serve as a benchmark for guiding policy efforts and interventions that aim to reduce stigma among TB patients in Afghanistan.

Facilitators and barriers to tuberculosis active case findings in low- and middle-income countries: a systematic review of qualitative research

BACKGROUND

Tuberculosis (TB) is an ancient infection and a major public health problem in many low- and middle-income countries (LMICs). Active case finding (ACF) programs have been established to effectively reduce TB in endemic global communities. However, there is little information about the evidence-based benefits of active case finding at both the individual and community levels. Accurately identifying the facilitators and barriers to TB-ACF provides information that can be used in planning and design as the world aims to end the global TB epidemic by 2035. Therefore, this study aimed to identify the facilitators and barriers to tuberculosis ACF in LMICs.

METHODS

A systematic search was performed using recognized databases such as PubMed, Google Scholar, SCOPUS, HINARI, and other reference databases. Relevant studies that assessed or reported the ACF of TB conducted in LMICs were included in this study. The Joanna Briggs Institute's (JBI) Critical Appraisal Tool was used to assess the quality of the selected studies. The Statement of Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) was used to strengthen the protocol for this systematic review. The Confidence of Evidence Review Quality (CERQual) approach was also used to assess the reliability of the review findings.

RESULTS

From 228 search results, a total of 23 studies were included in the final review. Tuberculosis ACF results were generated under two main themes: barriers and facilitators in LMICs, and two sub-themes of the barriers (healthcare-related and non-healthcare-related barriers). Finally, barriers to active TB case finding were found to be related to (1) the healthcare workers' experience, knowledge, and skills in detecting TB-ACF, (2) distance and time; (3) availability and workload of ACF healthcare workers; (4) barriers related to a lack of resources such as diagnostic equipment, reagents, and consumables at TB-ACF; (5) the stigma associated with TB-ACF detection; (6) the lack of training of existing and new healthcare professionals to detect TB-ACF; (7) communication strategies and language limitations associated with TB ACF; and (8) poor or no community awareness of tuberculosis. Stigma was the most patient-related obstacle to detecting active TB cases in LMICs.

CONCLUSION

This review found that surveillance, monitoring, health worker training, integration into health systems, and long-term funding of health facilities were key to the sustainability of ACF in LMICs. Understanding the elimination of the identified barriers is critical to ensuring a maximum tuberculosis control strategy through ACF.

Short Comprehensive Multimodal Behavioural Intervention for Tuberculosis-Can It Be Effectively Incorporated in Tribal Health?

BACKGROUND

Tuberculosis management in tribal areas is a major challenge to the National Tuberculosis Elimination Program in India. There is need for culturally appropriate interventions for bridging the gaps existing in the current system. There is paucity of research in this vulnerable group; hence, a study was undertaken to determine the effect of a Short Comprehensive Multimodal Behavioural Intervention in tribal colonies of Kerala.

METHODS

The study used before-after design to assess the effectiveness of a Short Comprehensive Multimodal Behavioural Intervention for tuberculosis knowledge and voluntary reporting among residents of tribal colonies. The intervention included individual, small group, and large group education, with verbal, printed, and performance methods. Public-private partnership with community participation was emphasized to encourage the residents to approach public health system for managing tuberculosis.

RESULTS

Ten tribal colonies from two districts were included with 104 participants. There was significant improvement in the proportion of participants with knowledge regarding different aspects of tuberculosis such as aetiology, symptoms, transmission, and treatment. The overall knowledge score had a significant improvement [median (range) 3.0 (0-9) to 7.0 (0-11), p < 0.001] when assessed one month consequent to the intense period of group education.

CONCLUSION

Short-term health behavioural intervention package appropriate for the target group, implemented with public-private partnership and community participation of trained local volunteers, proved effective in improving the knowledge regarding tuberculosis and thereby health-seeking behaviour in detection. This can be tested for scaling up, and replication in other tribal health issues.

Through service providers' eyes: health systems factors affecting implementation of tuberculosis control in Enugu State, South-Eastern Nigeria

Background

Well-functioning health systems are essential to achieving global and national tuberculosis (TB) control targets. This study examined health system factors affecting implementation of TB control programme from the perspectives of service providers.

Methods

The study was conducted in Enugu State, South-eastern Nigeria using qualitative, cross-sectional design involving 23 TB service providers (13 district TB supervisors and 10 facility TB focal persons). Data were collected through in-depth, semi-structured interviews using a health system dynamic framework and analysed thematically.

Results

Stewardship from National TB Control Programme (NTP) improved governance of TB control, but stewardship from local government was weak. Government spending on TB control was inadequate, whereas donors fund TB control. Poor human resources management practices hindered TB service delivery. TB service providers have poor capacity for data management because changes in recording and reporting tools were not matched with training of service providers. Drugs and other supplies to TB treatment centres were interrupted despite the use of a logistics agency. Poor integration of TB into general health services, weak laboratory capacity, withdrawal of subsidies to community volunteers and patent medicine vendors, poorly funded patient tracking systems, and ineffectual TB/HIV collaboration resulted in weak organisation of TB service delivery.

Conclusion

Health systems strengthening for TB control service must focus on effective oversight from NTP and local health system; predictable domestic resource mobilisation through budgets and social health insurance; training and incentives to attract and retain TB service providers; effective supply and TB drug management; and improvements in organization of service delivery.