Rapid assessment of facilitators and barriers related to the acceptance, challenges and community perception of daily regimen for treating tuberculosis in India

Stakeholders' perspective on the daily regimen of tuberculosis treatment- A qualitative approach

INTRODUCTION

In the context of changing over from an intermittent treatment regimen to a daily regimen, it becomes crucial to understand the impact of a daily regimen on the treatment process and outcome. It enables health professionals to strengthen strategies, to enhance the quality of treatment as well as the quality of life of TB patients. The perspective of each stakeholder involved in the process is important in assessing the impact of the daily regimen.

OBJECTIVES

To understand patients' and providers' perspectives on the daily regimen of Tuberculosis treatment.

METHODOLOGY

A qualitative study was conducted between March 2020 to June 2020, including in-depth interviews with TB patients on treatment and DOT providers, and Key Informant Interview(KII) with TB Health Visitors(TBHV) and family members of TB patients. A thematic-network analysis approach was utilized to get the results.

RESULTS

Two sub-themes emerged: (i) Acceptance of the daily regimen of treatment; (ii) operational difficulties of the daily regimen. No injections in the regimen, fewer side effects of drugs as dose depends on weight band, family members can be treatment supporter, awareness about disease and treatment, the drugs are as same as private drugs available, adherence has improved, monthly DBT were found to some of the enablers in the study. The Barriers found in the study were traveling daily to get drugs, loss of daily wages, accompanying patients daily, tracing private patients, pyridoxine is not given free in this regimen, increased workload for treatment providers, etc. CONCLUSION: The study points out that acceptance of the patient to the daily regimen is better as they have lesser side effects. The operational difficulties in the implementation of the daily regimen can be addressed by providing family members as treatment supporters.

Patient- and Health-System-Related Barriers to Treatment Adherence for Patients with Drug-Resistant Tuberculosis in the Philippines: A Mixed-Methods Study

Purpose

In the Philippines, drug-resistant tuberculosis (DRTB) is a growing concern. Healthcare workers face challenges in retaining patients with DRTB in care. This study intends to understand their perspectives on the factors that influence patient treatment outcomes and to propose potential programmatic solutions for strengthening care services for the patients.

Methods

A mixed-methods study was conducted in the Philippines between December 2017 and March 2018 to understand the major barriers for healthcare workers to provide quality care to DRTB patients across the care continuum. In the quantitative phase, healthcare workers participated in an online survey; in the qualitative phase, in-depth interviews were conducted with a select number of the survey respondents to better understand their survey responses.

Results

272 healthcare workers participated in the survey, and of those, 11 were interviewed. Survey results identified economic constraints, patient perceptions of care, family-related concerns, and limited accessibility to healthcare services as the major patient-related barriers across the care continuum. Major health-system-related barriers were insufficient human resources, lack of financial and political support, and limited knowledge about DRTB by healthcare providers. Interviews revealed more elaborate, contextualized, and nuanced aspects of each of the major challenges. The elaborated patient-related barriers included expenses needed during treatment (e.g., transportation); fear of being stigmatized by family, community, or healthcare staff; worries about adverse drug reactions from medication; a lack of family support; and the location of patients' homes. The health-system-related barriers revealed through interviews included the limited capacities of facility staff to provide DRTB care due to insufficient human resources; the shortage of funds to support treatment completion (e.g., transportation allowance and food package for patients, service vehicles and mobile phone costs for outreach actions at the facility level); and discrimination by healthcare staff against patients with DRTB attributed to the staff's limited knowledge and experiences of treating the patients.

Conclusion

This study identified the main barriers for DRTB facility staff in the Philippines from the perspectives of providers. Further exploration of the barriers and best practices in facilities may be useful for improving DRTB care in the Philippines.

Real-world implementation of video-observed therapy in an urban TB program in the United States

BACKGROUND:

Video directly observed therapy (vDOT) was introduced to increase flexibility and meet patient-specific needs for TB treatment. This study aimed to assess the reach and effectiveness of vDOT for TB treatment under routine conditions in Alameda County, CA, USA, a busy, urban setting, from 2018 to 2020.

METHODS:

We prospectively evaluated routinely collected data to estimate 1) reach (proportion of patients initiated on vDOT vs. in-person DOT); and 2) effectiveness (proportion of prescribed doses with verified administration by vDOT vs. in-person DOT).

RESULTS:

Among 163 TB patients, 94 (58%) utilized vDOT during treatment, of whom 54 (57%) received exclusively vDOT. Individuals receiving vDOT were on average younger than those receiving in-person therapy (46 vs. 61 years; P < 0.001). The median time to vDOT initiation was 2.2 weeks (IQR 1.1–10.0); patients were monitored for a median of 27.0 weeks (IQR 24.6–31.9). vDOT led to higher proportions of verified prescribed doses than in-person DOT (68% vs. 54%; P < 0.001). Unobserved self-administration occurred for all patients on weekends based on clinic instructions, but a larger proportion of doses were self-administered during periods of in-person DOT than of vDOT (45% vs. 24%; P < 0.001).

CONCLUSION:

A TB program successfully maintained vDOT, reaching the majority of patients and achieving greater medication verification than in-person DOT.

Facilities and difficulties in implementation of the tuberculosis control program in Primary Health Care

Introduction: The Brazilian National Tuberculosis Control Program was created to recommend and direct clinical actions, organizational setting, information systems and surveillance of tuberculosis. The process of implementation of control actions in Primary Care took place in several formats and with different outcomes, due to the influences of local organizational configuration. Objective: To identify the facilities and difficulties reported by nurses in the implementation of the Tuberculosis Control Program in Primary Health Care. Methods: A descriptive cross-sectional study with a quantitative approach, conducted in the city of Natal, Brazil. Data collected from November from 2017 to February 2018, with 80 nurses from Primary Health Care, through a structured questionnaire. Data were categorized according to similarity criteria and analyzed using descriptive statistics. Results: The availability of nurses to work in the program (47.5%) and the presence of materials (31.2%) were the most frequently mentioned facilities. The most frequently mentioned difficulties were: adherence to treatment (21.2%) and the performance of complementary tests (15.0%). Conclusion: The findings of the study may contribute to reflection and planning of actions by health teams, as well as a tool for local managers to organize their services, in order to ensure the person with tuberculosis comprehensive care.

Revisions in TB programme - boon or bane? A qualitative study exploring barriers and facilitators among health care workers in private and public sector, Kerala

BACKGROUND

Despite many serious and organized efforts worldwide, Tuberculosis (TB) remains one of the major public health concerns in many countries. India accounts for more than one quarter of global TB cases and deaths each year. India's National Tuberculosis Elimination Programme (NTEP) is the largest TB control program in the world, placing more than 100,000 patients on treatment every month. There have been so many revisions in the programme guidelines in the last 5 years. As we are gearing up for TB elimination in India, knowledge regarding the barriers is very crucial in the successful undertaking of these revised guidelines. Exploring perceptions of health care workers, both from the private and public sector will help to design appropriate strategies at the field level.

OBJECTIVE

To explore the barriers and facilitators among health care workers in the implementation of revised NTEP guidelines in a selected district of central Kerala.

METHODOLOGY

This qualitative study was conducted among health care workers from all levels involved in the implementation of NTEP from private and public sector. Qualitative data was collected through Focus Group Discussions (FGD) and Key Informant Interviews using a topic guide till data saturation. All discussions were audio recorded with the consent of participants. Sociogram was plotted to confirm equal participation of interviewees. A total of 4 FGDs (2 from each sector) and 12 Key informant interviews (7 from public sector and 5 from private sector) were conducted after obtaining written consent from the participants.

RESULTS

Overall awareness about revisions was found to be good. However, the study identified a "Gap between planners and implementers". Frequent nature of revisions without understanding the practical difficulties in the field, additional job responsibilities, inadequate knowledge among grass root level workers/private practioners in small clinics and increased side effects were the major barriers identified. In addition to that, insufficient logistics, not enthusiastic in learning revisions, fear of losing patients, delay in communication, decreased compliance with new regimen, increased out of pocket expenditure and grey areas in the current guidelines were also adversely affecting the successful implementation At the same time, facilitators like positive attitude and commitment of health care workers, introduction of M-health technology, strong public private partnership, inclusion of costly investigations in the revised guidelines, good administrative support, financial assistance, innovative initiatives like Treatment Support Groups (TSGs) and concept of Family Directly Observed Treatment Short-Course increased the effectiveness of the programme to a large extent.

CONCLUSION

The study identified gaps in knowledge, attitude and practice of revised guidelines at the field level. Gap between 'Planners and implementers could impede the successful implementation of TB Elimination programme and needs to be addressed.

Challenges in accessing and utilising health services for women accessing DOTS TB services in Kolkata, India

Challenges in accessing and utilising TB treatment are a major reason for the existing gaps in tuberculosis (TB) control in India. Twenty qualitative interviews were conducted with women who were attending or had attended a directly observed treatment short course (DOTS) clinic in Kolkata, India. The resulting data were analysed using a thematic approach. Our results indicated that women experienced several challenges categorised as (1) DOTS specific challenges, (2) lack of client friendly services, and (3) resource constraints. DOTS specific challenges included having to come to the clinic for medicines, lack of privacy, providers minimising contact with patients, length of treatment, drug side effects and pill burden. Lack of client friendly services led to mistrust in government services and a preference for private providers, which was compounded by corruption in the medical system. Inability to complete household duties due to inflexible clinic hours, long lines and overcrowded spaces, and mistreatment from providers were further challenges faced by women. Lastly, resource constraints meant women faced financial difficulties with additional treatment costs and suffered from lack of adequate food and nutrition. Our findings lead to several recommendations for addressing these challenges that should help improve women's experiences with DOTS TB treatment.

Mobile Health for Tuberculosis Management in South India: Is Video-Based Directly Observed Treatment an Acceptable Alternative?

Background

With the availability of low-cost mobile devices and the ease of internet access, mobile health (mHealth) is digitally revolutionizing the health sector even in resource-constrained settings. It is however necessary to assess end-user perceptions before deploying potential interventions.

Objective

This study aimed to assess the mobile phone usage patterns and the acceptability of mobile phone support during care and treatment in patients with tuberculosis (TB) in South India.

Methods

This exploratory study was conducted at an urban private tertiary care teaching hospital and nearby public primary-level health care facilities in Bangalore, South India. We recruited 185 patients with TB through consecutive sampling. Subsequent to written informed consent, participants responded to an interviewer-administered pretested questionnaire. The questionnaire included questions on demographics, phone usage patterns, and the benefits of using of mobile phone technology to improve health outcomes and treatment adherence. Frequency, mean, median, and SD or interquartile range were used to describe the data. Bivariate associations were assessed between demographics, clinical details, phone usage, and mHealth communication preferences using the chi-square test and odds ratios. Associations with a P value ≤.20 were included in a logistic regression model. A P value of <.05 was considered significant.

Results

Of the 185 participants, 151 (81.6%) used a mobile phone, and half of them owned a smartphone. The primary use of the mobile phone was to communicate over voice calls (147/151, 97.4%). The short message service (SMS) text messaging feature was used by only 66/151 (43.7%) mobile phone users. A total of 87 of the 151 mobile phone users (57.6%) knew how to use the camera. Only 41/151 (27.2%) mobile phone users had used their mobile phones to communicate with their health care providers. Although receiving medication reminders via mobile phones was acceptable to all participants, 2 participants considered repeated reminders as an intrusion of their privacy. A majority of the participants (137/185, 74.1%) preferred health communications via voice calls. Of the total participants, 123/185 (66.5%) requested reminders to be sent only at specific times during the day, 22/185 (11.9%) suggested reminders should synchronize with their prescribed medication schedule, whereas 40/185 (21.6%) did not have any time preferences. English literacy was associated with a preference for SMS in comparison with voice calls. Most participants (142/185, 76.8%) preferred video-based directly observed treatment when compared with in-person directly observed treatment.

Conclusions

Although mobile phones for supporting health and treatment adherence were acceptable to patients with TB, mHealth interventions should consider language, mode of communication, and preferred timing for communication to improve uptake.

Assessment of microbiological status after successful completion of intermittent revised national tuberculosis control programme directly observed treatment, short course regimen for microbiologically confirmed pulmonary tuberculosis cases: While new daily regimen going to be implemented in India

Purpose

The Revised National Tuberculosis Control Programme (RNTCP) is now introducing daily fixed-dose regimen instead of Directly Observed Treatment, Short Course (DOTS) regimen for treatment of drug-sensitive tuberculosis (TB) in India. It would be beneficial to understand the drawbacks, barriers and advantages of the existing system for better implementation of new policy. Our study was aimed to evaluate the current microbiological status of new microbiologically confirmed pulmonary TB patients who have successfully completed intermittent DOTS regimen within last 2 years and also to find the economic barriers faced by beneficiaries to avail DOTS treatment.

Materials and Methods

We included patients who had completed CAT 1 DOTS regimen within the last 2 years. The patients were interviewed. Sputum sample was collected for microscopy and cartridge-based nucleic acid amplification test.

Results

All patients were adhered to intermittent DOTS therapy, and sputum conversion rate was 83%. Minor gastrointestinal side effects were experienced by 60% of cases and 87% consumed drugs under supervision. On microbiological examination, 10% of the study population was found to be positive for TB and they all were rifampicin sensitive. Those who had completed treatment within 1 year with no clinical symptoms re-appeared after treatment.

Conclusion

Till date, RNTCP does not follow up the patients for any period of time after successful completion of treatment. Through the present study, we could find relapse cases in 10% of the previously treated non-symptomatic patients. These unnoticed relapse cases have potential to spread TB and increase disease burden of country. Thus, we can conclude that RNTCP has to follow up the patients after successful treatment to determine whether they relapse. It is needed for the success of programme and control of the disease in the country.