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Germano SNF, Erdmann AL, Albuquerque CF, Amante LN, Ferreira DS, Garrido MDS. Drug-resistant tuberculosis: integrative review of nursing care in primary health care. Rev Bras Enferm 2024; 77:e20230097. [PMID: 39045974 PMCID: PMC11259442 DOI: 10.1590/0034-7167-2023-0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 02/02/2024] [Indexed: 07/25/2024] Open
Abstract
OBJECTIVES to identify, in the scientific literature, the care that should be provided to individuals with drug-resistant tuberculosis by nurses in primary health care. METHODS integrative review, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses study selection flowchart. Data collection was conducted in November 2022, across ten databases. RESULTS six studies emphasized that nurses should perform directly observed treatment; two highlighted the importance of integrated care management between tuberculosis and human immunodeficiency virus; two demonstrated comprehensive nursing consultation using the nursing process; one emphasized person-centered care, with discharge planning and improved hospital communication with primary health care services. FINAL CONSIDERATIONS the care that nurses should provide to individuals with drug-resistant tuberculosis in primary health care, for care resolution, is evidence-based.
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McNabb KC, Bergman AJ, Patil A, Lowensen K, Mthimkhulu N, Budhathoki C, Perrin N, Farley JE. Travel distance to rifampicin-resistant tuberculosis treatment and its impact on loss to follow-up: the importance of continued RR-TB treatment decentralization in South Africa. BMC Public Health 2024; 24:578. [PMID: 38389038 PMCID: PMC10885440 DOI: 10.1186/s12889-024-17924-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Understanding why patients experience loss to follow-up (LTFU) is essential for TB control. This analysis examines the impact of travel distance to RR-TB treatment on LTFU, which has yet to be analyzed within South Africa. METHODS We retrospectively analyzed 1436 patients treated for RR-TB at ten South African public hospitals. We linked patients to their residential ward using data reported to NHLS and maps available from the Municipal Demarcation Board. Travel distance was calculated from each patient's ward centroid to their RR-TB treatment site using the georoute command in Stata. The relationship between LTFU and travel distance was modeled using multivariable logistic regression. RESULTS Among 1436 participants, 75.6% successfully completed treatment and 24.4% were LTFU. The median travel distance was 40.96 km (IQR: 17.12, 63.49). A travel distance > 60 km increased odds of LTFU by 91% (p = 0.001) when adjusting for HIV status, age, sex, education level, employment status, residential locale, treatment regimen, and treatment site. CONCLUSION People living in KwaZulu-Natal and Eastern Cape travel long distances to receive RR-TB care, placing them at increased risk for LTFU. Policies that bring RR-TB treatment closer to patients, such as further decentralization to PHCs, are necessary to improve RR-TB outcomes.
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Affiliation(s)
- Katherine C McNabb
- Johns Hopkins University School of Nursing, 525 N Wolfe St, Baltimore, MD, 21205, USA.
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Baltimore, MD, USA.
| | - Alanna J Bergman
- Johns Hopkins University School of Nursing, 525 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Baltimore, MD, USA
| | - Amita Patil
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Baltimore, MD, USA
| | - Kelly Lowensen
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Baltimore, MD, USA
| | - Nomusa Mthimkhulu
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Port Shepstone, Republic of South Africa
| | - Chakra Budhathoki
- Johns Hopkins University School of Nursing, 525 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Baltimore, MD, USA
| | - Nancy Perrin
- Johns Hopkins University School of Nursing, 525 N Wolfe St, Baltimore, MD, 21205, USA
| | - Jason E Farley
- Johns Hopkins University School of Nursing, 525 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Baltimore, MD, USA
- Johns Hopkins TB Research Advancement Center, Baltimore, MD, USA
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Rajkumar-Bhugeloo K, Moodley D, Mpotje T, Marakalala MJ. Host determinants of TB disease as targets for HDTs development: A study protocol. Wellcome Open Res 2023. [DOI: 10.12688/wellcomeopenres.19145.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
Tuberculosis (TB), caused by Mycobacterium tuberculosis (Mtb), remains a major global health challenge. New diagnostic and therapeutic strategies are required to curb TB transmission. Here we outline a protocol to validate inflammatory proteins as potential biomarkers of TB disease and to evaluate the candidate genes as potential targets for host-directed therapy (HDT) development. Blood will be isolated from healthy, latent TB infected (LTBI) individuals and TB patients, and expression profiles of genes of interest will be determined using qPCR. A human monocytic cell line will be utilized to knock down genes of interest and to evaluate their contribution to Mtb infection. Pharmaceutical interception of target genes will be performed in peripheral blood mononuclear cells (PBMCs) infected with Mtb. This work will result in identification of TB associated inflammatory markers that can also be targeted for HDT development.
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Khan U, Lotia-Farrukh I, Akhtar A, Khowaja SN, Khan S, Madhani F, Parekh A, Adnan S, Ahmed S, Chaudhry M, Hussain H, Habib A, Butt S, Siddiqui MR, Ijaz R, Jamal S, Khan AB, Keshavjee S, Khan AJ, Salahuddin N, Khan PY. Re-Evaluating the Merits of Decentralisation as a Core Strategy for Effective Delivery of Drug-Resistant Tuberculosis Care in Pakistan. Health Policy Plan 2022; 37:979-989. [PMID: 35527232 PMCID: PMC9384034 DOI: 10.1093/heapol/czac038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 04/04/2022] [Accepted: 05/08/2022] [Indexed: 11/14/2022] Open
Abstract
Decentralized, person-centred models of care delivery for drug-resistant tuberculosis (DR-TB) continue to be under-resourced in high-burden TB countries. The implementation of such models—made increasingly urgent by the COVID-19 pandemic—are key to addressing gaps in DR-TB care. We abstracted data of rifampicin-resistant (RR)/multidrug-resistant tuberculosis (MDR-TB) patients initiated on treatment at 11 facilities between 2010 and 2017 in Sindh and Balochistan provinces of Pakistan. We analysed trends in treatment outcomes relating to programme expansion to peri-urban and rural areas and estimated driving distance from patient residence to treatment facility. Among the 5586 RR/MDR-TB patients in the analysis, overall treatment success decreased from 82% to 66% between 2010 and 2017, as the programme expanded. The adjusted risk ratio for unfavourable outcomes was 1.013 (95% confidence interval 1.005–1.021) for every 20 km of driving distance. Our analysis suggests that expanding DR-TB care to centralized hubs added to increased unfavourable outcomes for people accessing care in peri-urban and rural districts. We propose that as enrolments increase, expanding DR-TB services close to or within affected communities is essential.
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Affiliation(s)
- Uzma Khan
- Interactive Research and Development, Karachi, Sindh, Pakistan
| | | | - Ahwaz Akhtar
- Indus Hospital and Health Network, Sindh, Pakistan
| | - Saira N Khowaja
- Interactive Research and Development, Karachi, Sindh, Pakistan
| | | | | | - Asra Parekh
- Interactive Research and Development, Karachi, Sindh, Pakistan
| | - Sana Adnan
- Indus Hospital and Health Network, Sindh, Pakistan
| | - Saman Ahmed
- Interactive Research and Development, Karachi, Sindh, Pakistan
| | - Mariam Chaudhry
- Interactive Research and Development, Karachi, Sindh, Pakistan
| | - Hamidah Hussain
- Interactive Research and Development, Karachi, Sindh, Pakistan
| | - Ali Habib
- Interactive Health Solutions, Karachi, Sindh, Pakistan
| | - Shahid Butt
- Indus Hospital and Health Network, Sindh, Pakistan
| | - Muhammad R Siddiqui
- Provincial TB Program, Sindh, Pakistan
- Institute of Chest Diseases, Kotri, Sindh, Pakistan
| | - Raafia Ijaz
- Indus Hospital and Health Network, Sindh, Pakistan
| | - Saba Jamal
- Indus Hospital and Health Network, Sindh, Pakistan
| | - Abdul B Khan
- Indus Hospital and Health Network, Sindh, Pakistan
| | - Salmaan Keshavjee
- Harvard University, Cambridge, Massachusetts, USA
- Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Aamir J Khan
- Interactive Research and Development, Karachi, Sindh, Pakistan
| | | | - Palwasha Y Khan
- Interactive Research and Development, Karachi, Sindh, Pakistan
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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5
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Gore R. Ensuring the ordinary: Politics and public service in municipal primary care in India. Soc Sci Med 2021; 283:114124. [PMID: 34265542 DOI: 10.1016/j.socscimed.2021.114124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/28/2021] [Accepted: 06/06/2021] [Indexed: 11/16/2022]
Abstract
This paper examines the political embeddedness of public-sector primary care in urban India. The low quality of urban healthcare in many low- and middle-income countries is well documented. But there is relatively little analysis showing how the politics of urban healthcare delivery contribute to quality shortfalls. This study integrates urban and political theory and draws on ethnographic fieldwork in municipal government-run primary care clinics in Pune, India. I conceptualize Pune's municipal doctors as street-level bureaucrats: frontline state agents charged with delivering public services, who regularly confront conflicts between their mandate and its realization in practice. I observe how the municipal doctors experience and respond to these conflicts; delineate the historical design of the municipal institutions in which they operate; and interview doctors, nurses, nonclinical staff, administrators, and elected officials, who collectively shape primary care delivery in municipal clinics. My findings show how the doctors' work is characterized by routine departures from public service ideals. The departures stem from local electoral politics (politicians' patronage and clientelistic relations with municipal employees and patients) and weak administrative capacity (misuse and incompetent planning of public resources). The doctors are compelled to follow extra-policy directives, meaning instructions that have little to do with healthcare goals and that emphasize the political utility rather than medical purpose of their work. In response, the doctors circumscribe their clinical practice. They aim, as one doctor put it, only to "ensure the ordinary," or to sustain a deficient status quo. In these conditions, improving quality of care requires not just behavioral interventions targeted at doctors. It requires normative, social, and organizational shifts in public service planning and delivery so that doctors are positioned - materially and affectively - to meet urban healthcare challenges in low-resource contexts.
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Affiliation(s)
- Radhika Gore
- Family Health Centers at NYU Langone, 5800 Third Ave, Brooklyn, NY 11220, United States.
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Osman M, Karat AS, Khan M, Meehan SA, von Delft A, Brey Z, Charalambous S, Hesseling AC, Naidoo P, Loveday M. Health system determinants of tuberculosis mortality in South Africa: a causal loop model. BMC Health Serv Res 2021; 21:388. [PMID: 33902565 PMCID: PMC8074279 DOI: 10.1186/s12913-021-06398-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/09/2021] [Indexed: 12/14/2022] Open
Abstract
Background Tuberculosis (TB) is a major public health concern in South Africa and TB-related mortality remains unacceptably high. Numerous clinical studies have examined the direct causes of TB-related mortality, but its wider, systemic drivers are less well understood. Applying systems thinking, we aimed to identify factors underlying TB mortality in South Africa and describe their relationships. At a meeting organised by the ‘Optimising TB Treatment Outcomes’ task team of the National TB Think Tank, we drew on the wide expertise of attendees to identify factors underlying TB mortality in South Africa. We generated a causal loop diagram to illustrate how these factors relate to each other. Results Meeting attendees identified nine key variables: three ‘drivers’ (adequacy & availability of tools, implementation of guidelines, and the burden of bureaucracy); three ‘links’ (integration of health services, integration of data systems, and utilisation of prevention strategies); and three ‘outcomes’ (accessibility of services, patient empowerment, and socio-economic status). Through the development and refinement of the causal loop diagram, additional explanatory and linking variables were added and three important reinforcing loops identified. Loop 1, ‘Leadership and management for outcomes’ illustrated that poor leadership led to increased bureaucracy and reduced the accessibility of TB services, which increased TB-related mortality and reinforced poor leadership through patient empowerment. Loop 2, ‘Prevention and structural determinants’ describes the complex reinforcing loop between socio-economic status, patient empowerment, the poor uptake of TB and HIV prevention strategies and increasing TB mortality. Loop 3, ‘System capacity’ describes how fragmented leadership and limited resources compromise the workforce and the performance and accessibility of TB services, and how this negatively affects the demand for higher levels of stewardship. Conclusions Strengthening leadership, reducing bureaucracy, improving integration across all levels of the system, increasing health care worker support, and using windows of opportunity to target points of leverage within the South African health system are needed to both strengthen the system and reduce TB mortality. Further refinement of this model may allow for the identification of additional areas of intervention.
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Affiliation(s)
- Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Aaron S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,The Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Munira Khan
- Tuberculosis and HIV Investigative Network (THINK), Durban, South Africa
| | - Sue-Ann Meehan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Arne von Delft
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,TB Proof, Cape Town, South Africa
| | - Zameer Brey
- Bill and Melinda Gates Foundation, Johannesburg, South Africa
| | - Salome Charalambous
- The Aurum Institute, Parktown, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marian Loveday
- HIV Prevention Research Unit, South African Medical Research Council, KwaZulu-Natal, Pietermaritzburg, South Africa.,South African Medical Research Council-CAPRISA-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
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7
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Kielmann K, Dickson-Hall L, Jassat W, Le Roux S, Moshabela M, Cox H, Grant AD, Loveday M, Hill J, Nicol MP, Mlisana K, Black J. 'We had to manage what we had on hand, in whatever way we could': adaptive responses in policy for decentralized drug-resistant tuberculosis care in South Africa. Health Policy Plan 2021; 36:249-259. [PMID: 33582787 PMCID: PMC8059133 DOI: 10.1093/heapol/czaa147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 11/16/2022] Open
Abstract
In 2011, the South African National TB Programme launched a policy of decentralized management of drug-resistant tuberculosis (DR-TB) in order to expand the capacity of facilities to treat patients with DR-TB, minimize delays to access care and improve patient outcomes. This policy directive was implemented to varying degrees within a rapidly evolving diagnostic and treatment landscape for DR-TB, placing new demands on already-stressed health systems. The variable readiness of district-level systems to implement the policy prompted questions not only about differences in health systems resources but also front-line actors' capacity to implement change in resource-constrained facilities. Using a grounded theory approach, we analysed data from in-depth interviews and small group discussions conducted between 2016 and 2018 with managers (n = 9), co-ordinators (n = 15), doctors (n = 7) and nurses (n = 18) providing DR-TB care. Data were collected over two phases in district-level decentralized sites of three South African provinces. While health systems readiness assessments conventionally map the availability of 'hardware', i.e. resources and skills to deliver an intervention, a notable absence of systems 'hardware' meant that systems 'software', i.e. health care workers (HCWs) agency, behaviours and interactions provided the basis of locally relevant strategies for decentralized DR-TB care. 'Software readiness' was manifest in four areas of DR-TB care: re-organization of service delivery, redressal of resource shortages, creation of treatment adherence support systems and extension of care parameters for vulnerable patients. These strategies demonstrate adaptive capacity and everyday resilience among HCW to withstand the demands of policy change and innovation in stressed systems. Our work suggests that a useful extension of health systems 'readiness' assessments would include definition and evaluation of HCW 'software' and adaptive capacities in the face of systems hardware gaps.
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Affiliation(s)
- Karina Kielmann
- Institute of Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Lindy Dickson-Hall
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
| | | | - Sacha Le Roux
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
| | - Mosa Moshabela
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
| | - Helen Cox
- Institute for Infectious Disease and Molecular Medicine and Wellcome Centre for Infectious Disease Research in Africa, University of Cape Town, Cape Town, South Africa
| | - Alison D Grant
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
- London School of Hygiene & Tropical Medicine, TB Centre, UK
- School of Public Health, University of the Witwatersrand, South Africa
| | - Marian Loveday
- Health Systems Research Unit, South African Medical Research Council
| | - Jeremy Hill
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
- London School of Hygiene & Tropical Medicine, TB Centre, UK
| | - Mark P Nicol
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
- Infection and Immunity, School of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Koleka Mlisana
- Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - John Black
- Department of Infectious Diseases, Livingstone Hospital, Lindsay Rd, Industrial, Port Elizabeth, 6020, South Africa
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Gray AT, Wood CE, Boyles T, Luedtke S, Birjovanu G, Hughes J, Kostkova P, Esmail H. Following Guidelines for Drug-Resistant Tuberculosis: “Yes, it’s a challenge”. FRONTIERS IN TROPICAL DISEASES 2021. [DOI: 10.3389/fitd.2021.645933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BackgroundDrug-resistant tuberculosis (DR-TB) is a major contributor to antimicrobial resistance (AMR) globally and is projected to be responsible for up to a quarter of AMR-associated deaths in the future. Management of DR-TB is increasingly decentralised to primary healthcare settings, and simultaneously becoming more complex due to a growing range of treatment options (e.g. novel agents, shorter regimens). This is reflected in the numerous recent updates to international guidelines and as such understanding the barriers and enablers to how healthcare workers access and use guidelines is vital.Materials and MethodsWe used an established psychological framework – the theoretical domains framework (TDF) – to construct and analyse an online survey and focus groups to explore healthcare workers current use of DR-TB guidelines in South Africa. We aimed to identify barriers and enablers with which to direct future attempts at improving guideline use.ResultsThere were 19 responses to the online survey and 14 participants in two focus groups. 28% used the most up-to-date national guidelines, 79% accessed guidelines primarily on electronic devices. The TDF domains of ‘Social Influences’ (mean Likert score = 4.3) and ‘Beliefs about Consequences’ (4.2) were key enablers, with healthcare workers encouraged to use guidelines and also recognising the value in doing so. ‘Environmental Resources’ (3.7) and ‘Knowledge’ (3.3) were key barriers with limited, or variable access to guidelines and lack of confidence using them being notable issues. This was most noted for certain subgroups: children, HIV co-infected, pregnant women (2.7).DiscussionCurrent use of DR-TB guidelines in South Africa is suboptimal. Planned interventions should focus on overcoming the identified key barriers and might include an increased use of digital tools.
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Gray AT, Boyles T, Luedtke S, Sossen B, Birjovanu G, Kostkova P, Hughes J, Esmail H. A threat to decentralised care for drug-resistant tuberculosis. THE LANCET RESPIRATORY MEDICINE 2020; 8:950-952. [PMID: 33007284 PMCID: PMC7524514 DOI: 10.1016/s2213-2600(20)30392-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/07/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Adam T Gray
- Department of Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK
| | - Tom Boyles
- University of Witwatersrand, Johannesburg, South Africa; Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Susanne Luedtke
- Institute for Risk and Disaster Reduction, Centre for Digital Public Health in Emergencies, University College London, London, UK
| | - Bianca Sossen
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Georgiana Birjovanu
- Institute for Risk and Disaster Reduction, Centre for Digital Public Health in Emergencies, University College London, London, UK
| | - Patty Kostkova
- Institute for Risk and Disaster Reduction, Centre for Digital Public Health in Emergencies, University College London, London, UK
| | - Jennifer Hughes
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, University of Stellenbosch, Cape Town, South Africa
| | - Hanif Esmail
- Institute for Global Health, University College London, London, UK; Medical Research Council Clinical Trials Unit, University College London, London, UK; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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