Qualitative Assessment of Challenges in Tuberculosis Control in West Gojjam Zone, Northwest Ethiopia: Health Workers' and Tuberculosis Control Program Coordinators' Perspectives

Development and validation of a risk prediction model for pulmonary tuberculosis among presumptive tuberculosis cases in Ethiopia

BACKGROUND

Early diagnosis and treatment of tuberculosis (TB) is one of the key strategies to achieve the WHO End TB targets. This study aimed to develop and validate a simple, convenient risk score to diagnose pulmonary TB among presumptive TB cases.

METHODS

This prediction model used Ethiopian national TB prevalence survey data and included 5459 presumptive TB cases from all regions of Ethiopia. Logistic regression was used to determine which variables are predictive of pulmonary TB. A risk prediction model was developed, incorporating significant variables (p<0.05). The Youden Index method was used to choose the optimal cut-off point to separate the risk score of the patients as high and low. Model performance was assessed using discrimination power and calibration. Internal validation of the model was assessed using Efron's enhanced bootstrap method, and the clinical utility of the risk score was assessed using decision curve analysis.

RESULTS

Of total participants, 94 (1.7%) were confirmed to have TB. The final prediction model included three factors with different scores: (1) TB contact history, (2) chest X-ray (CXR) abnormality and (3) two or more symptoms of TB. The optimal cut-off point for the risk score was 6 and was found to have a good discrimination accuracy (c-statistic=0.70, 95% CI: 0.65 to 0.75). The risk score has sensitivity of 51.1%, specificity of 79.9%, positive predictive value of 4.3% and negative predictive value of 98.9%. After internal validation, the optimism coefficient was 0.003, which indicates the model is internally valid.

CONCLUSION

We developed a risk score that combines TB contact, number of TB symptoms and CXR abnormality to estimate individual risk of pulmonary TB among presumptive TB cases. Though the score is easy to calculate and internally validated, it needs external validation before widespread implementation in a new setting.

Experience and Perception of Healthcare Workers on the Challenges of Follow-Up and Treatment of Tuberculosis Patients in Southern Ethiopia: An Exploratory-Descriptive Qualitative Study

Background

There is a scarcity of research evidence on TB follow-up and treatment challenges from a healthcare worker's perspective in Ethiopia. Therefore, this study aimed to explore and describe the experience and perception of healthcare workers on the challenges of follow-up and treatment of TB patients in Southern Ethiopia.

Material and Methods

A qualitative exploratory-descriptive study was employed among 26 purposely selected Healthcare Workers (HCWs) from Wolaita Sodo University-Comprehensive Specialized Hospital and Achura, Boloso Sore, and Tida Health Centers in December 2021 and January 2022. Initially, the maximum variation purposive sampling technique was employed, then based on the data requirement of the study it was enriched by a theoretical sampling method. The required data were collected through one-on-one face-to-face audio-taped in-depth interviews. Data analysis was conducted by using a qualitative data analysis framework for the applied research method. NVivo Software Version 11 was used to ease data organization and analysis. Detailed textual narration of subthemes, and themes was done using direct verbatim quotations in the respective headings and subheadings.

Results

In the current study, three major themes and eleven sub-themes emerged from the data. The three major themes include the experience of healthcare workers, perceived challenges, and suggestions for improvement of TB patients' follow-up and treatment. Healthcare worker's experience, compliance with infection prevention protocols, fear of contracting and/or spreading TB, public awareness of TB, socio-economic burdens, providers-related problems, shortage of medical supplies, unconducive physical work environment, provision of holistic support for the patients, provision of in or out of service training, and supportive supervision were the sub-themes.

Conclusion

This study explored the multidimensional challenges adjoining follow-up and treatment of TB patients. Regular monitoring and supportive supervision accompanied by appropriate and timely decisions and feedback are vital to ensure effective follow-up and treatment of TB patients in Ethiopia.

Who to Involve and Where to Start Integrating Tuberculosis Screening into Routine Healthcare Services: Positive Cough of Any Duration as the First Step for Screening Tuberculosis in Ethiopia

BACKGROUND

Recent country surveys have shown an unacceptably high prevalence of confirmed tuberculosis (TB) even among those with a low duration of cough, and more than 50% of those with bacteriologically confirmed pulmonary tuberculosis (PTB) do not report symptoms that correspond to presumptive TB. Furthermore, there has been an increase in the incidence of smear-negative PTB patients who can serve as a source of infection. We investigated whether screening people who sought healthcare for cough of any duration can increase TB case detection in Ethiopia, and compiled the lessons learned and recommendations.

METHODS

We carried out a facility-based study in Ethiopia. All consenting participants who sought any healthcare at the outpatients department, and healthcare facilities for reproductive and child health, anti-retroviral therapy, and diabetes were screened for cough of any duration, and those with cough underwent further investigations using chest radiography (CXR) (except for pregnant women, patients on anti-retroviral therapy, and diabetic patients) and microbiological tests. Confirmed cases were linked to TB treatment following the country's standard guidelines.

RESULTS

We screened 195,713 people who sought healthcare for cough of any duration. Of these, 2647 reported cough symptom of any duration, of whom 1853 underwent further diagnostic tests as they fulfilled the criteria for presumptive TB. Overall, 309/1853 (16.7%) were diagnosed with PTB and linked to TB treatment. Screening by cough of any duration and/or CXR improved TB case finding, and engaging all health teams (administrative and supportive staff, as well as healthcare providers) in the TB screening and diagnosis significantly improved the process.

CONCLUSION

Screening for TB using cough of any duration and/or CXR for any patient who sought healthcare has the potential to increase both the number of presumptive TB cases and the number of patients diagnosed with and treated for TB in Ethiopia. Such initiatives require strong engagement of facility staff, regular maintenance and calibration of TB diagnostic equipment, and uninterrupted reagent supplies.

Barriers and facilitators of nutrition assessment, counseling, and support for tuberculosis patients: a qualitative study

Background

Nutrition has a substantial role in the prevention, treatment, and cure of tuberculosis. Thus, nutrition assessment, counseling, and support (NACS) have been implemented as part of tuberculosis treatment. However, evidence on the barriers and facilitators (enablers) of its implementation is lacking.

Objective

To explore barriers and facilitators of implementation of NACS for tuberculosis patients.

Methods

An exploratory qualitative study was conducted in public health facilities and health offices of Mekelle City, Northern Ethiopia. We conducted 17 interviews using purposively selected key informants comprising health professionals (n = 12) and tuberculosis patients (n = 5). Interviews were tape-recorded, transcribed verbatim, and coded and analyzed using a thematic approach in ATLAS.ti 7 software.

Results

Barriers were identified at three levels -organization, care provider, and patient levels. Suboptimal nutritional supply, lack of supportive supervision, lack of adequate workforce, staff turn-over, the sudden withdrawal of partners, and weak link with social service were the barriers at the organization level. Lack of commitment was reported as the only barrier at the care provider level, and socioeconomic status of patients, sharing and selling of supplies, perceived improved status, and perceived stigma were identified as the major barriers for the implementation of nutrition assessment, counseling, and support service. While training, availability of measurement and educational tools, the inclusion of nutrition indicators in the tuberculosis register, and the presence of collaborating partners were identified as facilitators at the organizational level. Patients’ motivation to know their health status was reported to be a facilitator at the patient level.

Conclusions

Organization, care provider, and patient-level barriers and facilitators were found to influence the implementation of NACS. Hence, multilevel factors should be considered to successfully implement the program and to gain its potential impact.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-021-00463-x.

Need-based training of community health officers for tuberculosis care in Ahmednagar district of Maharashtra, India: A before and after study

BACKGROUND

Community health officers (CHOs) are a newly introduced cadre of mid-level health-care providers who will man the health and wellness centers under Ayushman Bharat Mission in India. Need-based training will help them fulfil their role in early diagnosis, treatment, and referral of tuberculosis (TB) patients. The present study identified the gaps in the awareness about TB in a heterogeneous group of trainees and addressed them through need-based training.

MATERIALS AND METHODS

A before and after the study was carried out in 110 trainee CHOs at Rural Medical College, Loni. In-depth interviews were conducted with public health experts and focus group discussion was conducted with trainees to gain the quality inputs. Structured questionnaires based on training objectives specifically pertaining to TB were designed. Training was provided with an emphasis on addressing the gaps identified in the pretest. Posttest evaluation was done at the end of the training to assess its effectiveness. Data were analyzed using the SPSS software version. 17.0 (Inc., Chicago, IL, USA).

RESULTS

The mean pretest score was 15.15 (standard deviation [SD] = 3.55) which improved after 6 months training to 24.01 (SD = 1.223), i.e., from 60% to 96%. There was highly significant improvement in overall knowledge score of trainees (t = 28.124, df = 109, P < 0.001). There was a statistically significant improvement in scores of all topics at the end of 6 months training in both Nursing and Ayurved graduates. Except for knowledge regarding the treatment of multidrug-resistant TB (P = 0.004), knowledge about all other topics was comparable in nursing and Ayurved graduates at the end.

CONCLUSIONS

Needs assessment proved effective in identifying the gaps in knowledge and skills of interdisciplinary trainee CHOs. Medical colleges with expertise in teaching, training, and health service provision can work with the public health system to provide a model for rapid upgrading and capacity building to meet health-care challenges such as TB.

Challenges in delivery of tuberculosis Services in Ethiopian Pastoralist Settings: clues for reforming service models and organizational structures

Background

The End-TB strategy aims to see a world free of tuberculosis (TB) by the coming decade through detecting and treating all cases irrespective of socioeconomic inequalities. However, case detections and treatment outcomes have not been as they should be in Somali pastoral settings of Ethiopia. Hence, this study aimed to explore the challenges that hinder the delivery and utilization of TB services in pastoral areas.

Methods

A qualitative study was conducted between December 2017 and October 2018 among pastoralist patients with delay of ≥2 months in seeking healthcare, healthcare providers and programme managers. Data were collected from different sources using 41 in-depth interviews, observations of facilities and a review meeting of providers from 50 health facilities. The data were transcribed, coded and analyzed to identify pre-defined and emerging sub-themes. ATLAS.ti version 7.0 was used for coding data, categorizing codes, and visualizing networks.

Results

Poor knowledge of TB and its services, limited accessibility (unreachability, unavailability and unacceptability), pastoralism, and initial healthcare-seeking at informal drug vendors that provide improper medications were the key barriers hindering the uptake of TB medical services. Inadequate infrastructure, shortage of trained and enthused providers, interruptions of drugs and laboratory supplies, scarce equipment, programme management gaps, lack of tailored approach, low private engagement, and cross-border movement were the major challenges affecting the provision of TB services for pastoral communities. The root factors were limited potential healthcare coverage, lack of zonal and district TB units, mobility and drought, strategy and funding gaps, and poor development infrastructure.

Conclusion

In pastoral settings of Ethiopia, the major challenges of TB services are limited access, illicit medication practices, inadequate resources, structural deficits, and lack of tailored approaches. Hence, for the pastoral TB control to be successful, mobile screening and treatment modalities and engaging rural drug vendors will be instrumental in enhancing case findings and treatment compliance; whereas, service expansion and management decentralization will be essential to create responsive structures for overcoming challenges.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06662-3.

Anti-Tuberculosis Commodities Management Performance and Factors Affecting It at Public Health Facilities in Dire Dawa City Administration, Ethiopia

Background

Health facilities (HFs) need extensive ranges of anti-tuberculosis (TB) drugs and related TB laboratory commodities (LCs) for diagnosis, prevention, and treatment of TB and multi-drug-resistance (MDR)-TB. This study was aimed to assess anti-TB commodities management performance at public HFs of Dire Dawa city administration, Ethiopia.

Methods

A cross-sectional study design in 16 HFs providing TB and MDR-TB related service using quantitative and qualitative method was conducted. Semi-structured questionnaires and observation checklists with logistic indicators assessment tools were used to collect data. We used an in-depth interview and analyzed using a thematic approach. Quantitative data were entered into Epi-Data version 3.1 and transported to SPSS version 20 to analyze the results. Chi-square was used to test the association and a P-value<0.05 was statistically significant.

Results

The majority(13; 81.3%) of HFs used a health commodity management information system. Forty-two (40%) bin cards (BCs) for first line anti-TB drugs were not updated, while 62.5% of BCs were updated for second line drugs. On average, 43% of HFs accurately reported a report and requisition format (RRF) had significant association with the presence of a logistic management information system (LMIS) and standard operating procedure (P=0.019). Of the HFs, 50% had good storage conditions and guidelines (P=0.041). Regimen change (56.3%; P=0.035), receive near expiry (56.3%; P=0.035), and defective practice to first expired-first-out (50%; P=0.007) were reasons for wastages. About 50% and 66.6% of HFs were stocked out for isoniazid 300 mg, rifampicin, isoniazid, pyrazinamide (RHZ fixed dose), and ethambutol 400 mg with a mean stock out duration of 10.8, 18.9, and 70.5 days, respectively. Regimen change (68.8%; P=0.026), low demand (56.3%; P=0.041), and delay to resupply (37.5%; P=0.041) were reasons for stock out of anti-TB commodities.

Conclusion

Anti-TB drugs and LCs management performance of the HFs were found to be defective, which was confirmed by unsatisfactory data records, inconstant reports, deprived stock record accuracy, long lead time, high stock out rate, wastages, defective storage conditions, lack of training, and management support. Hence, respective organizations should improve their responsible activities to secure an uninterrupted supply of anti-TB drugs and LCs.

A Qualitative Insight into Barriers to Tuberculosis Case Detection in East Gojjam Zone, Ethiopia

Tuberculosis (TB) remains to be the leading cause of morbidity and mortality in the developing world. Early TB case detection (TCD) and treatment of infectious cases is vital to reduce the TB burden. The objective of this study was to identify possible barriers to TCD in East Gojjam Zone, northwest Ethiopia. The study used a descriptive phenomenological research method. The study participants included 21 TB patients, six TB control officers, and 40 health workers (HWs) selected by a heterogeneous purposive sampling technique. In-depth interviews and focus group discussions were used to collect data. Interviews were audio recorded, transcribed verbatim, translated, and thematically analyzed using NVivo 12 software (developed by QSR International Qualitative Software Developer, Melbourne, Australia). The study participants identified numerous barriers to TCD which were grouped into three major themes and 14 subthemes: 1) patient-related barriers including rural residence, low income, poor health literacy, and health-seeking delay; 2) healthcare system barriers grouped into two subthemes: HWs barriers (shortage of HWs, lack of training access, and low level of knowledge and skills) and health facility barriers (health service delay, using only passive TCD strategy, poor health education provision, and lack of regular supervision and timely feedback); 3) sociocultural and environmental barriers which included stigma and discrimination, lack of health information sources, poor transportation infrastructure, and community resistance. In conclusion, the TCD activity which is one of the pillars of the TB control program has been confronted with several patient-related, environmental, and healthcare system-related barriers. Improving community health literacy, scale-up access, and improving quality of TB diagnostic services, conducting regular supportive supervision and provision of timely feedback, arranging regular refresher training and staff motivation and recruitment schemes, and engaging local health officials and political leaders to address budgetary problems for TB and transportation infrastructure challenges are imperative interventions to enhance the TCD efforts in the study area.

Bridging the gap between policy and practice: a qualitative analysis of providers' field experiences tinkering with directly observed therapy in patients with drug-resistant tuberculosis in Addis Ababa, Ethiopia

OBJECTIVES

Drug-resistant tuberculosis (DR-TB) is one of the major public health threats in low-income countries such as Ethiopia. It is intertwined with larger socioeconomic and political factors that complicate its management and control. Whether directly observed therapy (DOT) is serving its purpose-better patient adherence and treatment outcome-still remains a debatable issue. To contribute to this discussion, this study explored health workers' field experiences tinkering with DOT in patients with DR-TB in Addis Ababa, Ethiopia.

DESIGN

A qualitative study using in-depth interviews and focus group discussion.

SETTING

Ten public healthcare facilities: eight health centres at Addis Ababa Health Bureau level and two TB-specialised hospitals at the Federal Health Bureau level in Ethiopia.

PARTICIPANTS

18 healthcare providers working with DR-TB patients.

RESULTS

Three findings emerged from the analysis. First, the purpose of DOT is to ensure that patients go to healthcare facilities and swallow pills under the observation of a healthcare provider. Thus, its rigid application could lead to the emergence of more DR-TB. Second, DOT should be tinkered with and its practice improved by incorporating more counselling and health education, with more flexibility towards, and attentiveness of, patient context. Third, there exists a family-like patient-provider relationship, and providers do understand their patients and empathise with them to provide better healthcare services.

CONCLUSION

If rigidly implemented, DOT could lead to more DR-TB-a problem DOT was invented to resolve. Front-line healthcare providers are sensitive to the tragic experiences of DR-TB patients and empathise with them. Thus, they do not strictly implement DOT and are willing to take any blame resulting from tinkering with it. It is high time to shape the practice of DOT for DR-TB patients, with meaningful contributions from front-line healthcare providers.

Low Tuberculosis (TB) Case Detection: A Health Facility-Based Study of Possible Obstacles in Kaffa Zone, Southwest District of Ethiopia

Background

In Ethiopia, the national TB case detection rate is becoming improved; still some districts are not able to meet their case detection targets which leads to ongoing spread of TB infections to family members and communities. This study was intended to assess possible obstacles contributing to low TB case detection in Kaffa zone, Southwest Ethiopia.

Methods

A cross-sectional descriptive study involving qualitative and quantitative data was conducted from Mar. to Sep. 2019. Sociodemographic characteristics and data on duration of cough, whether sputum smear microscopy was requested or not, and data on TB knowledge and health care-seeking practice were collected from outpatients. Health care delivery barrier for TB case detection was also explored by using in-depth interview and FGD of health staff.

Results

From 802 outpatients with coughing for 2 or more weeks of duration, 334 (41.6%) of them were not requested to have TB microscopic diagnosis. Of these, 11/324 (3.4%) of them were positive for TB after sputum smear microscopy. Only 24.2% of the outpatients were aware as they have had health education on TB disease. Twenty-eight percent of patients perceived that TB was due to exposure to cold air, and 13.5% could not mention any sign or symptom of TB. Amazingly, 54.2% of them did not have any information as current TB diagnosis and treatment is free. Thirty-five percent of the patients were taking antibiotics before visiting the health facility. The interrupted supply of TB diagnostic reagents, frequent electricity interruption, shortage of trained TB care providers, weak health information system, and weak active case finding practice were explored as the factors contributing to low TB case detection.

Conclusion

Interrupted functioning of diagnostic centers, shortage of trained care providers, limited active TB case finding practice, weak health information system, and inadequate knowledge and health care-seeking practice of the patients were identified as contributors for low TB case detection. Thus, improving functioning of diagnostic centers, active TB case finding activities, and expanding health education on TB disease will help to improve TB case detection in the districts.

Burden of tuberculosis and challenges related to screening and diagnosis in Ethiopia

INTRODUCTION

One-third of tuberculosis (TB) cases in Ethiopia are missing from care for reasons that are not well studied. The aim of this study was to assess TB burden and identify challenges related to TB screening and diagnosis in Ethiopia.

METHODS

A facility-based cross-sectional study was conducted in seven health facilities selected from two regions and 2 city administrations of Ethiopia using stratified random sampling procedures. The data of 1,059,065 patients were included from outpatient department, HIV clinic, diabetic, and maternal-child health clinics. Data were collected from October to December 2018 using a retrospective review of three years' facility data (2015 to 2017) supplemented by a semi-structured interview with purposively selected health care workers and heads of the health facilities.

RESULTS

A total of 1,059,065 patients visited the health facilities in three years, of these, 978,480 (92.4%) were outpatients. Of the total, 20,284 (2%) were presumptive TB cases (with 14 days or more cough), 12.2% (2483/20,284) of which had TB. For the type of TB, 604 (24.3%) were smear-positive pulmonary TB (PTB), 789 (31.8%) were smear-negative PTB, 719 (29%) were extra-pulmonary TB, and data were missing for the rest. TB screening was integrated into HIV clinic, outpatient department, diabetic clinic but not with the maternal and child clinics. High patient load, weak TB laboratory specimen referral system, and shortage of TB diagnostic tools including Xpert MTB/RIF assay and chest X-ray, were the major challenges in the screening and diagnosis of TB.

CONCLUSION

The burden of TB was high in the study setting, and frequent interruption of laboratory reagents and supplies hampered TB screening and diagnostic services. Realizing the END-TB strategy in such resource-limited settings requires sustainable TB diagnostic capacity and improved case detection mechanisms, with national TB programs strongly integrated into the general health care system.

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.

Challenges of Tuberculosis Control in Lagos State, Nigeria: A Qualitative Study of Health-Care Providers' Perspectives

Background:

Tuberculosis (TB) burden in Nigeria is a reflection of the challenges of TB control strategy in the country. This study explored the challenges encountered by the health workers in public and private TB treatment centers in Lagos, Nigeria.

Methods:

In-depth interviews were held with 34 health workers providing TB services in private and public health facilities and the Lagos state Program Officer between October 1, 2016 and January 31, 2017. The transcripts were read severally and coded for qualitative data analysis. Themes were developed from coding.

Results:

Insufficient or lack of funds to track patients lost to follow-up, conduct home visits, collect drugs from the central stores, and shortage of laboratory reagents were some of the logistical challenges encountered by the health workers. There was shortage of health workers and some were yet to be trained resulting in work overload. This was situation aggravated by the frequent redeployment and health worker attrition in the public and private sector respectively.

Conclusion:

The government need be proactive and show leadership by finding lasting solutions to the logistical and human resource challenges facing the LAgos State TB and Leprosy Program.

Barriers for tuberculosis case finding in Southwest Ethiopia: A qualitative study

BACKGROUND

Ethiopia is one of the countries with a high burden of tuberculosis (TB). Jimma Zone has the lowest TB case notification rate compared to the national and World Health Organization's (WHO) targets. The aim of the present study was to identify barriers, and explore the origin of these barriers in relation to TB case finding.

METHODS

A qualitative study was conducted by using different data collection methods and sources. Sixty in-depth interviews with TB treatment providers, program managers and TB patients were included. In addition, 42 governmental health facilities were observed for availability of resources. Data obtained from the in-depth interviews were transcribed, coded, categorized and thematized. Atlas.ti version 7.1 software was used for the data coding and categorizing.

RESULTS

Inadequate resources for TB case finding, such as a shortage of health-care providers, inadequate basic infrastructure, and inadequate diagnostic equipment and supplies, as well as limited access to TB diagnostic services such as an absence of nearby health facilities providing TB diagnostic services and health system delays in the diagnostic process, were identified as barriers for TB case finding. We identified the absence of trained laboratory professionals in 11, the absence of clean water supply in 13 and the electricity in seven health facilities. Furthermore, we found that difficult topography, the absence of proper roads, an inadequate collaboration with other sectors (such as education), a turnover of laboratory professionals, and a low community mobilization, as the origin of some of these barriers.

CONCLUSION

Inadequate resources for TB case finding, and a limited access to diagnostic services, were major challenges affecting TB case finding. The optimal application of the directly observed treatment short course (Stop TB) strategy is crucial to increase the current low TB case notification rate. Practical strategies need to be designed to attract and retain health professionals in the health system.

Exploring local realities: Perceptions and experiences of healthcare workers on the management and control of drug-resistant tuberculosis in Addis Ababa, Ethiopia

BACKGROUND

Drug-resistant tuberculosis (DR-TB) remains a major health security threat worldwide. The effectiveness of implementation of DR-TB control strategies has been a subject of research and controversy. In resource-limited settings, using conventional medicine as the only framework to explain DR-TB gives a rather incomplete picture of the disease. This study intended to explore the perceptions and experiences of healthcare workers on the management and control of DR-TB in Addis Ababa, Ethiopia.

METHODS

The study employed a qualitative methodology with an inductive approach and a thematic analysis. It involved in-depth interviews with healthcare workers providing clinical services to DR-TB patients in 10 public healthcare facilities in Addis Ababa, Ethiopia.

RESULTS

A total of 18 healthcare workers participated until data saturation, which included 12 clinical nurses, four health officers and two medical laboratory technicians. The findings show that healthcare workers perceive DR-TB as a growing public health threat in Ethiopia, due to factors such as poverty, poor nutrition, crowded settings, healthcare worker and general public awareness of DR-TB, lack of good governance and culture.

CONCLUSION

The perspectives drawn from the healthcare workers shed more light on the image of DR-TB in a developing country context. It has been shown that understanding DR-TB is not confined to what can be drawn from the sphere of biomedicine. There are also interconnected barriers, which predict a dystopia in the epidemiology of DR-TB. Bringing DR-TB under control requires taking a step back from an overwhelming focus on the biomedical facets of the disease, and employ critical thinking on the wider social and structural forces as equally important targets.

Determinants of community-based health insurance implementation in west Gojjam zone, Northwest Ethiopia: a community based cross sectional study design

BACKGROUND

In most developing countries, healthcare cost is mainly paid at the time of sickness and out-of-pocket at the point of service delivery which potentially could inhibit access. The total economic cost of illness for households is also estimated to be frequently above 10% of household income which is categorized as catastrophic. The purpose of this study was to assess factors that determine decisions to join the community based health insurance in West Gojjam zone.

METHODS

A community based cross sectional survey was conducted to collect data from 690 household heads using a multistage sampling technique. A binary logistic regression was used to identify the determinants of household decisions for CBHI enrollment.

RESULTS

Out of the participants, 58% were CBHI members. Besides, family size (AOR = 1.17; CI = 1.02-1.35), average health status (AOR = .380; CI = .179-.805), chronic disease (AOR = 3.42; CI = 1.89-6.19); scheme benefit package adequacy (AOR = 2.17; CI = 1.20-3.93), perceived health service quality (AOR = 3.69; CI = 1.77-7.69), CBHI awareness (AOR = 4.90; CI = 1.65-14.4); community solidarity (AOR = 3.77; CI = 2.05-6.92) and wealth (AOR = 3.62; CI = 1.67-7.83) were significant determinant factors for enrolment in the community based health insurance scheme.

CONCLUSION

CBHI awareness, family health status, community solidarity, quality of service of health institutions, and wealth were major factors that most determine the household decisions to enroll in the system. Therefore, in-depth and sustainable awareness creation programs on the scheme; stratified premium- based on economic status of households; incorporation of social capital factors, particularly building community solidarity in the scheme implementation are vital to enhance sustainable enrollment. As perceived family health status and the existence of chronic disease were also found significant determinants of enrollment, the Government might have to look for options to make the scheme mandatory.

Measuring management's perspective of data quality in Pakistan's Tuberculosis control programme: a test-based approach to identify data quality dimensions

BACKGROUND

Data quality is core theme of programme's performance assessment and many organizations do not have any data quality improvement strategy, wherein data quality dimensions and data quality assessment framework are important constituents. As there is limited published research about the data quality specifics that are relevant to the context of Pakistan's Tuberculosis control programme, this study aims at identifying the applicable data quality dimensions by using the 'fitness-for-purpose' perspective.

RESULTS

Forty-two respondents pooled a total of 473 years of professional experience, out of which 223 years (47%) were in TB control related programmes. Based on the responses against 11 practical cases, adopted from the routine recording and reporting system of Pakistan's TB control programme (real identities of patient were masked), completeness, accuracy, consistency, vagueness, uniqueness and timeliness are the applicable data quality dimensions relevant to the programme's context, i.e. work settings and field of practice.

CONCLUSION

Based on a 'fitness-for-purpose' approach to data quality, this study used a test-based approach to measure management's perspective and identified data quality dimensions pertinent to the programme and country specific requirements. Implementation of a data quality improvement strategy and achieving enhanced data quality would greatly help organizations in promoting data use for informed decision making.

Factors affecting tuberculosis case detection in Kersa District, South West Ethiopia

BACKGROUND

Tuberculosis is one of the deadly communicable diseases which claim the lives of millions in the world. Early case detection and prompt treatment cures the patients, breaks the transmission and improves the control program.

OBJECTIVE

The aim of this study was to investigate the factors affecting tuberculosis case detection in Kersa District, south west Ethiopia.

METHOD

Facility based cross sectional study design was employed in four directly observed treatment short course service providing public health centers. Three hundred eighty four patient folders were reviewed. In-depth interviews was conducted with 18 health care workers including heads of health centers, tuberculosis focal persons, clinicians, laboratory technicians, tuberculosis program coordinator and head of health office.

RESULT

Significant number, 135(35.2%) of tuberculosis suspects were not requested for microscopic examination of sputum smear, the laboratory results 21(8.4%) of requested patients were not recorded in both patient folders and laboratory registers. Only 10 (4.4%) of those examined and recorded were smearing positive. Participants described that the shortage and irregular supply of acid fast bacilli reagents and consumable, inadequate infrastructures, frequent electricity interruption, shortage of trained care providers, negligence of care providers, weakness of laboratory quality assurance system and poor health information use culture were major factors for low case identification.

CONCLUSION

The resource shortage, electricity interruption, low commitment of care providers, weak quality assurance practice and poor health information use culture were major factors for low tuberculosis case identification and should be considered.

Protocol for a qualitative synthesis of barriers and facilitators in implementing guidelines for diagnosis of tuberculosis

INTRODUCTION

Despite the introduction of new tests and guidelines for diagnosis of tuberculosis (TB), worldwide case detection rate of TB is still suboptimal. This could be in part explained by the poor implementation of TB diagnostic guidelines. We aim to identify, appraise and synthesise qualitative evidence exploring the barriers and facilitators to implementing TB diagnostic guidelines.

METHODS AND ANALYSIS

A systematic review of qualitative studies will be conducted. Relevant electronic databases will be searched and studies included based on predefined inclusion criteria. We will also search reference lists, grey literature, conduct forward citation searches and contact relevant content experts. An adaptation of the Critical Appraisal Skills Programme tool will be used to assess the methodological quality of included studies. Two authors will review the search output, extract data and assess methodological quality independently, resolving any disagreements by consensus. We will use the thematic framework analysis approach based on the Supporting the Use of Research Evidence thematic framework to analyse and synthesise our data. We will apply the Confidence in the Evidence from Reviews of Qualitative research approach to transparently assess our confidence in the findings of the systematic review.

ETHICS AND DISSEMINATION

This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42016039790 TRIAL REGISTRATION NUMBER: PROSPERO 2016: CRD42016039790. Available from http://www.crd.york.ac.uk/PROSPERO/.

Patients' and health system's delays in the diagnosis and treatment of new pulmonary tuberculosis patients in West Gojjam Zone, Northwest Ethiopia: a cross-sectional study

Background

Tuberculosis (TB) is a major public health concern in the developing world. Early diagnosis and prompt initiation of treatment is essential for effective TB control. The aim of this study was to determine the length and analyze associated factors of patients’ and health system’s delays in the diagnosis and treatment of new pulmonary TB (PTB) patients.

Methods

A cross-sectional study was conducted in 30 randomly selected public health facilities in West Gojjam Zone, Amhara Region, Ethiopia. Newly diagnosed PTB patients who were ≥15 years of age were consecutively enrolled in the study. Patients’ delay (the time period from onset of TB symptoms to first presentation to a formal health provider) and health system’s delay (the time period from first presentation to a formal health provider to first start of TB treatment) were measured. Median patients’ and health system’s delays were calculated. Mixed effect logistic regression was used to analyze predictors of patients’ and health system’s delays.

Results

Seven hundred six patients were enrolled in the study. The median patients’ delay was 18 days (interquartile range [IQR]: 8–34 days) and the median health system’s delay was 22 days (IQR: 4–88 days). Poor knowledge of TB (adjusted odds ratio [AOR], 2.33; 95 % confidence interval [CI], 1.34–4.05), first visit to non-formal health provider (AOR, 47.56; 95 % CI, 26.31–85.99), self-treatment (AOR, 10.11; 95 % CI, 4.53–22.56) and patients’ age (≥45 years) (AOR, 2.99; 95 % CI, 1.14–7.81) were independent predictors of patients’ delay. Smear-negative TB (AOR, 1.88; 95 % CI, 1.32–2.68) and first visit to public health centers (AOR, 2.22; 95 % CI, 1.52–3.25) and health posts (AOR, 5.86; 95 % CI, 1.40–24.39) were found to be independent predictors of health system’s delay.

Conclusions

The health system’s delay in this study was long and contributed more than 50 % of the total delay. Better TB diagnostic tools to complement sputum smear microscopy are needed to early diagnose PTB cases at peripheral health facilities. In addition, due emphasis should be given to increase public awareness about symptoms and consequences of TB disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1995-z) contains supplementary material, which is available to authorized users.

Total Delay Is Associated with Unfavorable Treatment Outcome among Pulmonary Tuberculosis Patients in West Gojjam Zone, Northwest Ethiopia: A Prospective Cohort Study

BACKGROUND

delay in diagnosis and treatment of tuberculosis (TB) may worsen the disease, increase mortality and enhance transmission in the community. This study aimed at assessing the association between total delay and unfavorable treatment outcome among newly diagnosed pulmonary TB (PTB) patients.

METHODS

A prospective cohort study was conducted in West Gojjam Zone, Amhara Region of Ethiopia from October 2013 to May 2015. Newly diagnosed PTB patients who were ≥15 years of age were consecutively enrolled in the study from 30 randomly selected public health facilities. Total delay (the time period from onset of TB symptoms to first start of anti-TB treatment) was measured. Median total delay was calculated. Mixed effect logistics regression was used to analyze factors associated with unfavorable treatment outcome.

RESULTS

Seven hundred six patients were enrolled in the study. The median total delay was 60 days. Patients with total delay of > 60 days were more likely to have unfavorable TB treatment outcome than patients with total delay of ≤ 60 days (adjusted odds ratio [AOR], 2.33; 95% confidence interval [CI], 1.04-5.26). Human immunodeficiency virus (HIV) positive TB patients were 8.46 times more likely to experience unfavorable treatment outcome than HIV negative TB patients (AOR, 8.46; 95% CI, 3.14-22.79).

CONCLUSIONS

Long total delay and TB/HIV coinfection were associated with unfavorable treatment outcome. Targeted interventions that can reduce delay in diagnosis and treatment of TB, and early comprehensive management of TB/HIV coinfection are needed to reduce increased risk of unfavorable treatment outcome.