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Lestari BW, Hadisoemarto PF, Afifah N, McAllister S, Fattah D, Salindri AD, van Crevel R, Murray M, Hill PC, Alisjahbana B. Tuberculosis care provided by private practitioners in an urban setting in Indonesia: Findings from a standardized patient study. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003311. [PMID: 38833456 PMCID: PMC11149835 DOI: 10.1371/journal.pgph.0003311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 05/13/2024] [Indexed: 06/06/2024]
Abstract
In Indonesia, government-owned Community Health Centers (CHCs) spearhead tuberculosis (TB) care at the primary level, but a substantial proportion of individuals with pulmonary TB also seek care from Private Practitioners (PPs). However, little is known about PPs' practice in managing patients with TB-associated symptoms. To avoid bias associated with self-administered surveys, we used standardized patients (SPs) to evaluate PPs' adherence to the national TB guidelines. Four clinical scenarios of individuals presenting complaints suggestive of TB, accompanied by different sputum smear results or TB treatment histories were developed. We assigned 12 trained SPs to PPs practicing in 30 CHC catchment areas in Bandung city, Indonesia. For comparison, two scenarios were also presented to the CHCs. A total of 341 successful SP visits were made to 225 private general practitioners (GPs), 29 private specialists, and 30 CHCs. When laboratory results were not available, adherence to the recommended course of action, i.e., sputum examination, was low among private GPs (31%) and private specialists (20%), while it was requested in 87% of visits to the CHCs. PPs preferred chest X-ray (CXR) in all scenarios, with requests made in 66% of visits to private GPs and 84% of visits to private specialists (vs. 8% CHCs). Prescriptions of incorrect TB drug regimens were reported from 7% and 13% of visits to private GPs and specialists, respectively, versus none of the CHCs. Indonesian PPs have a clear preference for CXR over microbiological testing for triaging presumptive TB patients, and inappropriate prescription of TB drugs is not uncommon. These findings warrant actions to increase awareness among PPs about the importance of microbiological testing and of administering appropriate TB drug regimens. SP studies can be used to assess the impact of these interventions on providers' adherence to guidelines.
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Affiliation(s)
- Bony Wiem Lestari
- Tuberculosis Working Group, Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
- Department of Public Health, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Panji F. Hadisoemarto
- Tuberculosis Working Group, Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
- Department of Public Health, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
- Centre for International Health, Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | - Nur Afifah
- Tuberculosis Working Group, Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
| | - Susan McAllister
- Centre for International Health, Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | - Deny Fattah
- Tuberculosis Working Group, Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
| | - Argita D. Salindri
- Tuberculosis Working Group, Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Megan Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Philip C. Hill
- Centre for International Health, Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | - Bachti Alisjahbana
- Tuberculosis Working Group, Research Center for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
- Department of Internal Medicine, Faculty of Medicine Universitas Padjadjaran, Dr Hasan Sadikin General Hospital, Bandung, Indonesia
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Orangi S, Orangi T, Kabubei KM, Honda A. Understanding factors influencing the use of clinical guidelines in low-income and middle-income settings: a scoping review. BMJ Open 2023; 13:e070399. [PMID: 37344115 DOI: 10.1136/bmjopen-2022-070399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023] Open
Abstract
OBJECTIVE A scoping review was undertaken to determine the extent to which existing studies have examined factors influencing healthcare providers' use of clinical guidelines in low and middle-income country (LMIC) settings and determine which factors constrain or facilitate the use of clinical guidelines by healthcare providers. DESIGN Scoping review. DATA SOURCES The literature search was conducted using PubMed in January 2021. ELIGIBILITY CRITERIA We identified empirical studies, published between 2011-2021 in English, which included clinicians and/or nurses as healthcare providers, used a health facility as the study site, and were located in an LMIC. DATA EXTRACTION AND SYNTHESIS Information extracted from the literature review was organised using themes and the findings synthesised using thematic analysis. RESULTS The review identified five types of interacting factors that influence healthcare providers' use of and compliance with clinical guidelines. The factors identified are organisational factors, factors relating to individual healthcare providers, attributes of the clinical guidelines, patient-related factors and institutional factors. Organisational factors can be further divided into the physical work environment, organisational culture and working conditions. The effective use of clinical guidelines in LMIC settings is greatly impacted by the contextualisation of clinical guidelines, end-user engagement and alignment of the implementation of clinical guidelines with the institutional arrangements in the broader health system. CONCLUSION The development and evaluation of concrete interventions is vital to facilitate the implementation of clinical guidelines and improve healthcare service quality. Further studies are necessary to examine the relative importance of the five identified factors on the effective use of clinical guidelines in different contexts.
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Affiliation(s)
- Stacey Orangi
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Tiffany Orangi
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Ayako Honda
- Research Center for Health Policy and Economics, Hitotsubashi Institute for Advanced Study, Hitotsubashi University, Tokyo, Japan
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McLaren ZM, Sharp AR, Zhou J, Wasserman S, Nanoo A. Assessing healthcare quality using routine data: evaluating the performance of the national tuberculosis programme in South Africa. Trop Med Int Health 2016; 22:171-179. [PMID: 27886429 DOI: 10.1111/tmi.12819] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the performance of healthcare facilities by means of indicators based on guidelines for clinical care of TB, which is likely a good measure of overall facility quality. METHODS We assessed quality of care in all public health facilities in South Africa using graphical, correlation and locally weighted kernel regression analysis of routine TB test data. RESULTS Facility performance falls short of national standards of care. Only 74% of patients with TB provided a second specimen for testing, 18% received follow-up testing and 14% received drug resistance testing. Only resistance testing rates improved over time, tripling between 2004 and 2011. National awareness campaigns and changes in clinical guidelines had only a transient impact on testing rates. The poorest performing facilities remained at the bottom of the rankings over the period of study. CONCLUSION The optimal policy strategy requires both broad-based policies and targeted resources to poor performers. This approach to assessing facility quality of care can be adapted to other contexts and also provides a low-cost method for evaluating the effectiveness of proposed interventions. Devising targeted policies based on routine data is a cost-effective way to improve the quality of public health care provided.
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Affiliation(s)
- Zoë M McLaren
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Alana R Sharp
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Jifang Zhou
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Sean Wasserman
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ananta Nanoo
- Centre for Tuberculosis, National Institute for Communicable Diseases, Johannesburg, South Africa
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Implementation and Operational Research: What Happens After a Negative Test for Tuberculosis? Evaluating Adherence to TB Diagnostic Algorithms in South African Primary Health Clinics. J Acquir Immune Defic Syndr 2016; 71:e119-26. [PMID: 26966843 PMCID: PMC4804742 DOI: 10.1097/qai.0000000000000907] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction and Background: Diagnostic tests for tuberculosis (TB) using sputum have suboptimal sensitivity among HIV-positive persons. We assessed health care worker adherence to TB diagnostic algorithms after negative sputum test results. Methods: The XTEND (Xpert for TB—Evaluating a New Diagnostic) trial compared outcomes among people tested for TB in primary care clinics using Xpert MTB/RIF vs. smear microscopy as the initial test. We analyzed data from XTEND participants who were HIV positive or HIV status unknown, whose initial sputum Xpert MTB/RIF or microscopy result was negative. If chest radiography, sputum culture, or hospital referral took place, the algorithm for TB diagnosis was considered followed. Analysis of intervention (Xpert MTB/RIF) effect on algorithm adherence used methods for cluster-randomized trials with small number of clusters. Results: Among 4037 XTEND participants with initial negative test results, 2155 (53%) reported being or testing HIV positive and 540 (14%) had unknown HIV status. Among 2155 HIV-positive participants [684 (32%) male, mean age 37 years (range, 18–79 years)], there was evidence of algorithm adherence among 515 (24%). Adherence was less likely among persons tested initially with Xpert MTB/RIF vs. smear [14% (142/1031) vs. 32% (364/1122), adjusted risk ratio 0.34 (95% CI: 0.17 to 0.65)] and for participants with unknown vs. positive HIV status [59/540 (11%) vs. 507/2155 (24%)]. Conclusions: We observed poorer adherence to TB diagnostic algorithms among HIV-positive persons tested initially with Xpert MTB/RIF vs. microscopy. Poor adherence to TB diagnostic algorithms and incomplete coverage of HIV testing represents a missed opportunity to diagnose TB and HIV, and may contribute to TB mortality.
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Qualitative Assessment of Challenges in Tuberculosis Control in West Gojjam Zone, Northwest Ethiopia: Health Workers' and Tuberculosis Control Program Coordinators' Perspectives. Tuberc Res Treat 2016; 2016:2036234. [PMID: 27066271 PMCID: PMC4811263 DOI: 10.1155/2016/2036234] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/11/2016] [Accepted: 02/18/2016] [Indexed: 11/30/2022] Open
Abstract
Background. Weak health systems pose many barriers to effective tuberculosis (TB) control. This study aimed at exploring health worker's and TB control program coordinator's perspectives on health systems challenges facing TB control in West Gojjam Zone, Amhara Region, Ethiopia. Methods. This was a qualitative descriptive study. Eight in-depth interviews with TB control program coordinators and two focus group discussions among 16 health workers were conducted. Purposive sampling was used to recruit study participants. Thematic analysis was used to identify and analyse main themes. Results. We found that intermittent interruptions of laboratory reagents and anti-TB drugs supplies, absence of trained and motivated health workers, poor TB data documentation, lack of adherence to TB treatment guideline, and lack of access to TB diagnostic tools at peripheral health institutions were challenges facing the TB control program performance in the study zone. Conclusions. Ensuring uninterrupted supply of anti-TB drugs and laboratory reagents to all health institutions is essential. Continuous refresher training of health workers on standard TB care and data handling and developing and implementing a sound retention strategy to attract and motivate health professionals to work in rural areas are necessary interventions to improve the TB control program performance in the study zone.
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Huang F, Zhang H, Lv Q, Sato KD, Qu Y, Huan S, Cheng J, Zhao F, Wang L. Use of anti-tuberculosis drugs among newly diagnosed pulmonary tuberculosis inpatients in China: a retrospective study. Infect Dis Poverty 2016; 5:2. [PMID: 26792535 PMCID: PMC4720996 DOI: 10.1186/s40249-016-0098-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 01/04/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND China's national tuberculosis control program (NTP) provides free, first-line anti-tuberculosis (TB) drugs to pulmonary TB patients. This treatment regimen follows the World Health Organization's (WHO) guideline. The objective of this paper is to evaluate the current status of anti-TB drug use for newly diagnosed pulmonary TB inpatients treated in prefecture- and county-level designated hospitals. METHODS Three prefecture-level hospitals and nine county-level hospitals were selected for the study. All newly diagnosed pulmonary TB inpatient medical records from 2012 were reviewed and doubly examined by two national senior physicians. The rational use of anti-TB drugs was evaluated based on criteria in line with WHO's guideline. RESULTS Of the 2,060 total treatment regimens for TB, 53.1 % were found to be rational (1093/2060). The percentages in prefecture-level and county-level hospitals were 50.3 % (761/1513) and 60.7 % (332/547), respectively. The difference between the two levels of hospitals was statistically significant (Chi-square value = 17.44, P < 0.01). The percentages of rational treatment regimens for first-time hospitalizations and for two or more hospitalizations were 59.5 % (983/1653) and 27.0 % (110/407), respectively, with a statistically significant difference (Chi-square value = 138.00, P < 0.01). The overall use of second-line drugs (SLD) was 54.9 % (1131/2060). The percentages for prefecture-level and county-level hospitals were 50.6 % (766/1513) and 66.7 % (365/547), respectively. A statistically significant difference was found (Chi-square value = 42.06, P < 0.01). The use of SLD for inpatients hospitalized once and inpatients hospitalized twice or more was 58.4 % (966/1653) and 40.5 % (165/407), respectively, with a statistically significant difference (Chi-square value = 42.26, P < 0.01). CONCLUSIONS Half of inpatients might be treated with irrational regimens, and the use of SLD was more appropriately dispensed in city-level hospitals than in county-level hospitals. Trainings and guidelines for health personnel, supervision led by health authorities and increased investment to designated hospitals may help to improve the rational use of anti-TB drugs.
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Affiliation(s)
- Fei Huang
- National Center for TB control and prevention, No 155 Changbai Road, Changping District, Beijing, 102206, China.
| | - Hui Zhang
- National Center for TB control and prevention, No 155 Changbai Road, Changping District, Beijing, 102206, China.
| | - Qing Lv
- National Center for TB control and prevention, No 155 Changbai Road, Changping District, Beijing, 102206, China.
| | | | - Yan Qu
- National Center for TB control and prevention, No 155 Changbai Road, Changping District, Beijing, 102206, China.
| | - Shitong Huan
- Bill & Melinda Gates Foundation, Beijing office, Beijing, China.
| | - Jun Cheng
- National Center for TB control and prevention, No 155 Changbai Road, Changping District, Beijing, 102206, China.
| | - Fei Zhao
- National Center for TB control and prevention, No 155 Changbai Road, Changping District, Beijing, 102206, China.
| | - Lixia Wang
- National Center for TB control and prevention, No 155 Changbai Road, Changping District, Beijing, 102206, China.
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de Andrade EDT, Hennington ÉA, de Siqueira HR, Rolla VC, Mannarino C. Perspectives of Patients, Doctors and Medical Students at a Public University Hospital in Rio de Janeiro Regarding Tuberculosis and Therapeutic Adherence. PLoS One 2015; 10:e0137572. [PMID: 26360291 PMCID: PMC4567070 DOI: 10.1371/journal.pone.0137572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 08/18/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction The World Health Organization (WHO) identifies 8.7 million new cases of tuberculosis (TB) annually around the world. The unfavorable outcomes of TB treatment prevent the achievement of the WHO’s cure target. Goal To evaluate existing intersections in the conceptions relative to the knowledge of TB, the experience of the illness and the treatment. Methods Doctors, medical students and patients were selected from a public university in Rio de Janeiro, Brazil, from 2011 to 2013. The data were obtained by semi-structured individual and focus group interviews, participant observation and a field journal. The inclusion of patients was interrupted due to saturation, and the inclusion of doctors and medical students stopped due to exhaustion. The theoretical background included symbolic Interactionism, and the analysis used rounded Theory. The analysis prioritized the actions/interactions axis. Results Twenty-three patients with pulmonary TB, seven doctors and 15 medical students were included. In the interviews, themes such as stigma, self-segregation, and difficulties in assistance emerged, in addition to defense mechanisms such as denial, rationalization, isolation and other mental mechanisms, including guilt, accountability and concealment of the disease. Aspects related to the assistance strategy, the social support network, bonding with the healthcare staff and the doctor-patient relationship were highlighted as adherence enablers. Doctors and students recommended an expansion of the theoretical and practical instruction on TB during medical students’ education. The existence of health programs and policies was mentioned as a potential enabler of adherence. Conclusion The main concepts identified were the stigma, self-segregation, guilt, responsibility, concealment and emotional repercussions. In relation to the facilitation of therapeutic adherence, the concepts identified were the bonds with healthcare staff, the doctor-patient relationship, assistance and educational health strategies.
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MESH Headings
- Brazil
- Female
- Guideline Adherence
- Health Knowledge, Attitudes, Practice
- Hospitalists/psychology
- Hospitals, Public/standards
- Hospitals, Public/statistics & numerical data
- Hospitals, University/standards
- Hospitals, University/statistics & numerical data
- Humans
- Patients/psychology
- Stereotyping
- Students, Medical/psychology
- Tuberculosis, Pulmonary/epidemiology
- Tuberculosis, Pulmonary/psychology
- Tuberculosis, Pulmonary/therapy
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Affiliation(s)
| | - Élida Azevedo Hennington
- National Institute of Infectious Diseases Evandro Chagas (INI/Fiocruz), Rio de Janeiro, Brazil
- Deputy Direction of Education, National Institute of Infectious Diseases Evandro Chagas (INI/Fiocruz), Rio de Janeiro, Brazil
| | | | - Valeria Cavalcanti Rolla
- National Institute of Infectious Diseases Evandro Chagas (INI/Fiocruz), Rio de Janeiro, Brazil
- Clinical Research Laboratory on Mycobacteria, National Institute of Infectious Diseases Evandro Chagas (INI/Fiocruz), Rio de Janeiro, Brazil
| | - Celina Mannarino
- National Institute of Infectious Diseases Evandro Chagas (INI/Fiocruz), Rio de Janeiro, Brazil
- Deputy Direction of Education, National Institute of Infectious Diseases Evandro Chagas (INI/Fiocruz), Rio de Janeiro, Brazil
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Mala G, Spigt MG, Gidding LG, Blanco R, Dinant GJ. Quality of diagnosis and monitoring of tuberculosis in Northern Ethiopia: medical records-based retrospective study. Trop Doct 2015; 45:214-20. [PMID: 25883064 DOI: 10.1177/0049475515581126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine quality of diagnosis and monitoring of treatment response of patients with smear-negative pulmonary tuberculosis (TB) compared with smear-positive cases in Ethiopia. METHODS A retrospective analysis of medical records of newly diagnosed pulmonary TB cases that were registered for taking anti-TB medication and had completed treatment between 2010 and 2012. We evaluated the percentage of cases that were managed according to the International Standards of Tuberculosis Care (ISTC) and compared smear-negative with smear-positive cases. RESULTS We analysed 1168 cases of which 742 (64%) were sputum smear-negative cases. Chest radiography examination at diagnosis and microbiological testing at the end of the intensive phase of treatment was performed in a smaller proportion than in smear-positive TB cases (70% vs. 79%, P value <0.001) and (70% vs. 95%, P value <0.001), respectively. CONCLUSIONS Clinical actions recommended in the ISTC are of greatest importance in minimising pitfalls in care of smear-negative TB yet were performed less often in smear-negative than smear-positive TB cases.
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Affiliation(s)
- George Mala
- MSc, Department of Medicine, Mekelle University, Mek'ele, Ethiopia MSc, Department of Family Medicine, Maastricht University/CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands
| | - Mark G Spigt
- PhD, Department of Family Medicine, Maastricht University/CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands PhD, Department of General Practice, Tromsø University, Tromsø, Norway
| | - Luc G Gidding
- MD, Department of Family Medicine, Maastricht University/CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands
| | - Roman Blanco
- MD, Department of Surgery, Universidad de Alcala, Alcala, Spain
| | - Geert-Jan Dinant
- MD, PhD, Department of Family Medicine, Maastricht University/CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands
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