1
|
Maynard C, Tariq S, Sotgiu G, Migliori GB, van den Boom M, Field N. Psychosocial support interventions to improve treatment outcomes for people living with tuberculosis: a mixed methods systematic review and meta-analysis. EClinicalMedicine 2023; 61:102057. [PMID: 37457116 PMCID: PMC10338299 DOI: 10.1016/j.eclinm.2023.102057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 07/18/2023] Open
Abstract
Background People with tuberculosis (TB) face multi-dimensional barriers when accessing and engaging with care. There is evidence that providing psychosocial support within people-centered models of care can improve TB outcomes, however, there is limited consensus on what works. It remains important for such interventions to be rigorously assessed, and mixed methods systematic reviews are one way of synthesising data for policy makers to be able to access such evidence. Mixed methods reviews take a complexity perspective, with qualitative data being used to contextualise the quantitative findings and giving an insight into how interventions are contingent on variations in design and context. Methods Five electronic databases were searched from January 1 2015 to 14 January 2023 for randomised controlled trials, quasi-experimental trials, cohort studies and qualitative studies of interventions providing psychosocial support (material and/or psychological-based support) to adults with any clinical form of active TB. Studies with inpatient treatment as the standard of care were excluded. Quantitative studies reporting pre-specified standard TB outcomes were eligible. In line with established mixed methods review methodology, a convergent parallel-results synthesis design was followed: quantitative and qualitative syntheses were distinct and carried out using appropriate methods. A convergent coding matrix was then used to integrate the results. The protocol was registered on PROSPERO (CRD42021235211). Findings Twenty-three studies of interventions were included (12 quantitative, 10 qualitative, and 1 mixed methods study) were included. Most studies were conducted in low-and middle-income countries with a high-burden of TB. Three explanatory and contextual middle-range theories from the integration of qualitative and quantitative data were developed: effective interventions provide multi-dimensional support; psychological-based support is transformative but there is insufficient evidence that it improves treatment outcomes on its own; intervention delivery shapes a logic of care. Interpretation This review takes a complexity perspective to provide actionable and timely insight to inform the design and implementation of locally-appropriate and people-centered psychosocial support interventions within national TB programmes. Funding There was no funding source for this study.
Collapse
Affiliation(s)
| | | | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Italy
| | | | | | - Nigel Field
- UCL Institute for Global Health, UK
- Centre for Molecular Epidemiology and Translational Research, UCL Institute for Global Health, UK
| |
Collapse
|
2
|
Marley G, Zou X, Nie J, Cheng W, Xie Y, Liao H, Wang Y, Tao Y, Tucker JD, Sylvia S, Chou R, Wu D, Ong J, Tang W. Improving cascade outcomes for active TB: A global systematic review and meta-analysis of TB interventions. PLoS Med 2023; 20:e1004091. [PMID: 36595536 PMCID: PMC9847969 DOI: 10.1371/journal.pmed.1004091] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/18/2023] [Accepted: 12/13/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To inform policy and implementation that can enhance prevention and improve tuberculosis (TB) care cascade outcomes, this review aimed to summarize the impact of various interventions on care cascade outcomes for active TB. METHODS AND FINDINGS In this systematic review and meta-analysis, we retrieved English articles with comparator arms (like randomized controlled trials (RCTs) and before and after intervention studies) that evaluated TB interventions published from January 1970 to September 30, 2022, from Embase, CINAHL, PubMed, and the Cochrane library. Commentaries, qualitative studies, conference abstracts, studies without standard of care comparator arms, and studies that did not report quantitative results for TB care cascade outcomes were excluded. Data from studies with similar comparator arms were pooled in a random effects model, and outcomes were reported as odds ratio (OR) with 95% confidence interval (CI) and number of studies (k). The quality of evidence was appraised using GRADE, and the study was registered on PROSPERO (CRD42018103331). Of 21,548 deduplicated studies, 144 eligible studies were included. Of 144 studies, 128 were from low/middle-income countries, 84 were RCTs, and 25 integrated TB and HIV care. Counselling and education was significantly associated with testing (OR = 8.82, 95% CI:1.71 to 45.43; I2 = 99.9%, k = 7), diagnosis (OR = 1.44, 95% CI:1.08 to 1.92; I2 = 97.6%, k = 9), linkage to care (OR = 3.10, 95% CI = 1.97 to 4.86; I2 = 0%, k = 1), cure (OR = 2.08, 95% CI:1.11 to 3.88; I2 = 76.7%, k = 4), treatment completion (OR = 1.48, 95% CI: 1.07 to 2.03; I2 = 73.1%, k = 8), and treatment success (OR = 3.24, 95% CI: 1.88 to 5.55; I2 = 75.9%, k = 5) outcomes compared to standard-of-care. Incentives, multisector collaborations, and community-based interventions were associated with at least three TB care cascade outcomes; digital interventions and mixed interventions were associated with an increased likelihood of two cascade outcomes each. These findings remained salient when studies were limited to RCTs only. Also, our study does not cover the entire care cascade as we did not measure gaps in pre-testing, pretreatment, and post-treatment outcomes (like loss to follow-up and TB recurrence). CONCLUSIONS Among TB interventions, education and counseling, incentives, community-based interventions, and mixed interventions were associated with multiple active TB care cascade outcomes. However, cost-effectiveness and local-setting contexts should be considered when choosing such strategies due to their high heterogeneity.
Collapse
Affiliation(s)
- Gifty Marley
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- University of North Carolina Project-China, Guangzhou, China
| | - Xia Zou
- Global Health Research Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Juan Nie
- Department of Research and Education, Guangzhou Concord Cancer Center, Guangzhou, China
| | - Weibin Cheng
- Institute for Healthcare Artificial Intelligence Application, Guangdong Second Provincial General Hospital, Guangzhou, China
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Yewei Xie
- University of North Carolina Project-China, Guangzhou, China
| | - Huipeng Liao
- University of North Carolina Project-China, Guangzhou, China
| | - Yehua Wang
- University of North Carolina Project-China, Guangzhou, China
| | - Yusha Tao
- University of North Carolina Project-China, Guangzhou, China
| | - Joseph D. Tucker
- University of North Carolina Project-China, Guangzhou, China
- Faculty of Infectious and Tropical Diseases, London School of Health and Tropical Medicine, London, United Kingdom
| | - Sean Sylvia
- University of North Carolina Project-China, Guangzhou, China
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Roger Chou
- Oregon Health & Science University, Portland, Oregon, United States of America
| | - Dan Wu
- University of North Carolina Project-China, Guangzhou, China
- Faculty of Infectious and Tropical Diseases, London School of Health and Tropical Medicine, London, United Kingdom
| | - Jason Ong
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Weiming Tang
- Dermatology Hospital of Southern Medical University, Guangzhou, China
- University of North Carolina Project-China, Guangzhou, China
- * E-mail:
| |
Collapse
|
3
|
Beidas RS, Dorsey S, Lewis CC, Lyon AR, Powell BJ, Purtle J, Saldana L, Shelton RC, Stirman SW, Lane-Fall MB. Promises and pitfalls in implementation science from the perspective of US-based researchers: learning from a pre-mortem. Implement Sci 2022; 17:55. [PMID: 35964095 PMCID: PMC9375077 DOI: 10.1186/s13012-022-01226-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 07/20/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Implementation science is at a sufficiently advanced stage that it is appropriate for the field to reflect on progress thus far in achieving its vision, with a goal of charting a path forward. In this debate, we offer such reflections and report on potential threats that might stymie progress, as well as opportunities to enhance the success and impact of the field, from the perspective of a group of US-based researchers. MAIN BODY Ten mid-career extramurally funded US-based researchers completed a "pre-mortem" or a group brainstorming exercise that leverages prospective hindsight to imagine that an event has already occurred and to generate an explanation for it - to reduce the likelihood of a poor outcome. We came to consensus on six key themes related to threats and opportunities for the field: (1) insufficient impact, (2) too much emphasis on being a "legitimate science," (3) re-creation of the evidence-to-practice gap, (4) difficulty balancing accessibility and field coherence, (5) inability to align timelines and priorities with partners, and (6) overly complex implementation strategies and approaches. CONCLUSION We submit this debate piece to generate further discussion with other implementation partners as our field continues to develop and evolve. We hope the key opportunities identified will enhance the future of implementation research in the USA and spark discussion across international groups. We will continue to learn with humility about how best to implement with the goal of achieving equitable population health impact at scale.
Collapse
|
4
|
Puchalski Ritchie LM, Kip EC, Mundeva H, van Lettow M, Makwakwa A, Straus SE, Hamid JS, Zwarenstein M, Schull MJ, Chan AK, Martiniuk A, van Schoor V. Process evaluation of an implementation strategy to support uptake of a tuberculosis treatment adherence intervention to improve TB care and outcomes in Malawi. BMJ Open 2021; 11:e048499. [PMID: 34215610 PMCID: PMC8256754 DOI: 10.1136/bmjopen-2020-048499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess implementation and to identify barriers and facilitators to implementation, sustainability and scalability of an implementation strategy to provide lay health workers (LHWs) with the knowledge, skills and tools needed to implement an intervention to support patient tuberculosis (TB) treatment adherence. DESIGN Mixed-methods design including a cluster randomised controlled trial and process evaluation informed by the RE-AIM framework. SETTING Forty-five health centres (HCs) in four districts in the south east zone of Malawi, who had an opportunity to receive cascade training. PARTICIPANTS Forty-five peer-trainers (PTs), 23 patients and 20 LHWs. INTERVENTION Implementation strategy employing peer-led educational outreach, a clinical support tool and peer support network to implement a TB treatment adherence intervention. OUTCOME MEASURES Process data were collected from study initiation to the end-of-study PT meeting, and included: LHW and patient interviews, quarterly PT meeting notes, training logs and study team observations and meeting notes. Data sources were first analysed in isolation, followed by method, data source and analyst triangulation. Analyses were conducted independently by two study team members, and themes revised through discussion and involvement of additional study team members as needed. RESULTS Forty-one HCs (91%) trained at least one LHW. Of 256 LHWs eligible to participate at study start 152 (59%) completed training, with the proportion trained per HC ranging from 0% to 100% at the end of initial cascade training. Lack of training incentives was the primary barrier to implementation, with intrinsic motivation to improve knowledge and skills, and to improve patient care and outcomes the primary facilitators of participation. CONCLUSION We identified important challenges to and potential facilitators of implementation, scalability and sustainability, of the TB treatment adherence intervention. Findings provide guidance to scale-up, and use of the implementation strategies employed, to address LHW training and supervision in other areas. TRIAL REGISTRATION NUMBER NCT02533089.
Collapse
Affiliation(s)
- Lisa M Puchalski Ritchie
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Knowledge Translation Program, St Michael's Hospital Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
- Emergency Medicine, University Health Netowrk, Toronto, Ontario, Canada
- Institute of Health policy, management, and evaluation, university of toronto, toronto, ontario, canada
| | | | - Hayley Mundeva
- Knowledge Translation Program, St Michael's Hospital Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi
- University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | | | - Sharon E Straus
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Knowledge Translation Program, St Michael's Hospital Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Jemila S Hamid
- Department of Mathematics and Statistics, University of Ottawa, Ottawa, Ontario, Canada
| | - Merrick Zwarenstein
- Family Medicine, Schulich School of Medicine and Dentistry Department of Family Medicine, London, Ontario, Canada
| | - Michael J Schull
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Adrienne K Chan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alexandra Martiniuk
- The George Institute for Global Health, Newtown, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | | |
Collapse
|
5
|
Puchalski Ritchie LM, van Lettow M, Makwakwa A, Kip EC, Straus SE, Kawonga H, Hamid JS, Lebovic G, Thorpe KE, Zwarenstein M, Schull MJ, Chan AK, Martiniuk A, van Schoor V. Impact of a tuberculosis treatment adherence intervention versus usual care on treatment completion rates: results of a pragmatic cluster randomized controlled trial. Implement Sci 2020; 15:107. [PMID: 33308257 PMCID: PMC7731739 DOI: 10.1186/s13012-020-01067-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 12/01/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND With the global shortage of skilled health workers estimated at 7.2 million, outpatient tuberculosis (TB) care is commonly task-shifted to lay health workers (LHWs) in many low- and middle-income countries where the shortages are greatest. While shown to improve access to care and some health outcomes including TB treatment outcomes, lack of training and supervision limit the effectiveness of LHW programs. Our objective was to refine and evaluate an intervention designed to address common causes of non-adherence to TB treatment and LHW knowledge and skills training needs. METHODS We employed a pragmatic cluster randomized controlled trial. Participants included 103 health centres (HCs) providing TB care in four districts in Malawi, randomized 1:1 stratified by district and HC funding (Ministry of Health, non-Ministry funded). At intervention HCs, a TB treatment adherence intervention was implemented using educational outreach, a point-of-care reminder tool, and a peer support network. Clusters in the control arm provided usual care. The primary outcome was the proportion of patients with successful TB treatment (i.e., cure or treatment completion). We used a generalized linear mixed model, with district as a fixed effect and HC as a random effect, to compare proportions of patients with treatment success, among the trial arms, with adjustment for baseline differences. RESULTS We randomized 51 HCs to the intervention group and 52 HCs to the control group. Four intervention and six control HCs accrued no eligible patients, and 371 of 1169 patients had missing outcome, HC, or demographic data, which left 74 HCs and 798 patients for analysis. Randomization group was not related to missing outcome, however, district, age, and TB type were significantly related and included in the primary analysis model. Among the 1153 patients with HC and demographic data, 297/605 (49%) and 348/548 (64%) in the intervention and control arms, respectively, had treatment success. The intervention had no significant effect on treatment success (adjusted odds ratio 1.35 [95% confidence interval 0.93-1.98]). CONCLUSION We found no significant effect of the intervention on TB treatment outcomes with high variability in implementation quality, highlighting important challenges to both scale-up and sustainability. TRIAL REGISTRATION ClinicalTrials.gov NCT02533089 . Registered August 20, 2015.
Collapse
Affiliation(s)
- Lisa M. Puchalski Ritchie
- Department of Medicine, University of Toronto, 6 Queen’s Park Crescent West, Third Floor, Toronto, ON M5S 3H2 Canada
- Li Ka Shing Knowledge Institute, St. Michaels Hospital, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada
- Department of Emergency Medicine, University Health Network, Toronto General Hospital, 200 Elizabeth Street, RFE G-480, Toronto, M5G 2C4 Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, M5T 3M7 Canada
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, M5T 3M7 Canada
| | | | | | - Sharon E. Straus
- Department of Medicine, University of Toronto, 6 Queen’s Park Crescent West, Third Floor, Toronto, ON M5S 3H2 Canada
- Li Ka Shing Knowledge Institute, St. Michaels Hospital, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada
| | | | - Jemila S. Hamid
- School of Epidemiology and Public Health, University of Ottawa, Room 101, 600 Peter Morand Crescent, Ottawa, ON I1G 5Z3 Canada
| | - Gerald Lebovic
- Li Ka Shing Knowledge Institute, St. Michaels Hospital, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, M5T 3M7 Canada
| | - Kevin E. Thorpe
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, M5T 3M7 Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada
| | - Merrick Zwarenstein
- Department of Family Medicine, Western University, London, ON Canada
- Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, 1151 Richmond St, London, ON N6A 5C1 Canada
| | - Michael J. Schull
- Department of Medicine, University of Toronto, 6 Queen’s Park Crescent West, Third Floor, Toronto, ON M5S 3H2 Canada
- Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Center, University of Toronto, c/o H2-66, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
- Dignitas International Toronto, C/O ICES attention Michael Schull, 2075 Bayview Avenue, G106, Toronto, ON M4N 3M5 Canada
| | - Adrienne K. Chan
- Department of Medicine, University of Toronto, 6 Queen’s Park Crescent West, Third Floor, Toronto, ON M5S 3H2 Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, M5T 3M7 Canada
- Dignitas International, Zomba, Malawi
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, M5T 3M7 Canada
- Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Center, University of Toronto, c/o H2-66, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| | - Alexandra Martiniuk
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, M5T 3M7 Canada
- George Institute for Global Health, Sydney, Australia
- The University of Sydney, Edward Ford Building, Sydney, NSW Australia
| | | |
Collapse
|
6
|
Puchalski Ritchie LM, Mundeva H, van Lettow M, Straus SE, Kip E, Makwakwa A. Impact of peer-trainer leadership style on uptake of a peer led educational outreach intervention to improve tuberculosis care and outcomes in Malawi: a qualitative study. BMC Health Serv Res 2020; 20:513. [PMID: 32503525 PMCID: PMC7275352 DOI: 10.1186/s12913-020-05386-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 06/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background Little is known about how to build leadership capacity to support implementation of evidence-based practices within health systems. We observed substantial variability across sites in uptake and sustainability of a peer-led educational outreach intervention for lay health workers (LHWs) providing tuberculosis care in Malawi. Feedback from peer-trainers (PTs) suggested that leadership may have contributed to the variation. We sought to assess the impact of PT leadership style on implementation, and to identify leadership traits of more successful PTs, to inform future implementation planning and to identify targets for leadership capacity building. Methods Qualitative study employing interviews with PTs and LHWs at high and low implementation sites, and review of study team and quarterly PT meeting notes. High implementation sites achieved high uptake, sustainability and fidelity of implementation including: close adherence to training content and process, high levels of coverage (training most or all eligible LHWs at their site), and outcomes were achieved with high levels of self reported competence with the intervention among both PTs and LHWs. Low implementation sites achieved limited coverage (<= 50% of LHWs trained), and intervention fidelity. Results Eight PTs and 10 LHWs from eight high and 10 low implementation sites participated in interviews. Leadership traits of more successful PTs included: flexibility in their approach to training, role modeling and provision of supportive supervision to support learning; addressing challenges proactively and as they occurred; collaborative planning; knowledgeable; and availability to support implementation. Traits unique to less successful PTs included: a poor attitude toward their role as PT and a passive-avoidant approach to challenges. Conclusion This study identified leadership traits more common among unit level leaders at sites with higher uptake, sustainability, and fidelity of implementation. These findings provide a starting point for development and evaluation of a leadership capacity building intervention for unit level leaders to support implementation.
Collapse
Affiliation(s)
- L M Puchalski Ritchie
- Department of Medicine, University of Toronto, Toronto, Canada. .,Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michaels Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,Department of Emergency Medicine, University Health Network, Toronto, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - H Mundeva
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michaels Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - S E Straus
- Department of Medicine, University of Toronto, Toronto, Canada.,Department of Emergency Medicine, University Health Network, Toronto, Canada
| | - E Kip
- Dignitas International, Zomba, Malawi
| | - A Makwakwa
- National TB Program, Ministry of Health, PO Box 30377, Lilongwe, Malawi
| |
Collapse
|
7
|
A systematic review of non-pharmacological interventions to improve therapeutic adherence in tuberculosis. Heart Lung 2019; 48:452-461. [PMID: 31084923 DOI: 10.1016/j.hrtlng.2019.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 04/30/2019] [Accepted: 05/01/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Reviews examining non-pharmacological interventions to improve therapeutic adherence in tuberculosis have several limitations (design, quality assessment…). Consequently, for clinical practice, it is important to generate a review containing all the information to improve patient adherence, solving the previous issues. OBJECTIVES To examine non-pharmacological interventions to improve therapeutic adherence in tuberculosis through clinical trials. METHODS A systematic review in MEDLINE/EMBASE was performed. RESULTS Thirty seven papers were analysed. The disease treatment interventions were disparate, grouped into: education, psychological interventions, new technologies, directly observed treatment, incentives and improved access to health services. In the treatment of latent infection, the majority of studies were conducted in the marginal population (drug addicts, homeless individuals and prisoners) and were based mainly on the provision of incentives. Study quality was generally low. CONCLUSIONS Great variability exists in the studies comparing strategies for identifying interventions, objectives and effects. The designs carried out generally have methodological deficits.
Collapse
|
8
|
Klein K, Bernachea MP, Irribarren S, Gibbons L, Chirico C, Rubinstein F. Evaluation of a social protection policy on tuberculosis treatment outcomes: A prospective cohort study. PLoS Med 2019; 16:e1002788. [PMID: 31039158 PMCID: PMC6490910 DOI: 10.1371/journal.pmed.1002788] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 03/25/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) still represents a major public health problem in Latin America, with low success and high default rates. Poor adherence represents a major threat for TB control and promotes emergence of drug-resistant TB. Expanding social protection programs could have a substantial effect on the global burden of TB; however, there is little evidence to evaluate the outcomes of socioeconomic support interventions. This study evaluated the effect of a conditional cash transfer (CCT) policy on treatment success and default rates in a prospective cohort of socioeconomically disadvantaged patients. METHODS AND FINDINGS Data were collected on adult patients with first diagnosis of pulmonary TB starting treatment in public healthcare facilities (HCFs) from 16 health departments with high TB burden in Buenos Aires who were followed until treatment completion or abandonment. The main exposure of interest was the registration to receive the CCT. Other covariates, such as sociodemographic and clinical variables and HCFs' characteristics usually associated with treatment adherence and outcomes, were also considered in the analysis. We used hierarchical models, propensity score (PS) matching, and inverse probability weighting (IPW) to estimate treatment effects, adjusting for individual and health system confounders. Of 941 patients with known CCT status, 377 registered for the program showed significantly higher success rates (82% versus 69%) and lower default rates (11% versus 20%). After controlling for individual and system characteristics and modality of treatment, odds ratio (OR) for success was 2.9 (95% CI 2, 4.3, P < 0.001) and default was 0.36 (95% CI 0.23, 0.57, P < 0.001). As this is an observational study evaluating an intervention not randomly assigned, there might be some unmeasured residual confounding. Although it is possible that a small number of patients was not registered into the program because they were deemed not eligible, the majority of patients fulfilled the requirements and were not registered because of different reasons. Since the information on the CCT was collected at the end of the study, we do not know the exact timing for when each patient was registered for the program. CONCLUSIONS The CCT appears to be a valuable health policy intervention to improve TB treatment outcomes. Incorporating these interventions as established policies may have a considerable effect on the control of TB in similar high-burden areas.
Collapse
Affiliation(s)
- Karen Klein
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Maria Paula Bernachea
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Sarah Irribarren
- Biobehavioral Nursing and Health Informatics, University of Washington, School of Nursing HSB, Seattle, Washington, United States of America
| | - Luz Gibbons
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Cristina Chirico
- Tuberculosis Control Program of the 5th Health Region, Ministry of Health of the Province of Buenos Aires, Hospital Cetrángolo, Buenos Aires, Argentina
| | - Fernando Rubinstein
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
- * E-mail:
| |
Collapse
|
9
|
Alipanah N, Jarlsberg L, Miller C, Linh NN, Falzon D, Jaramillo E, Nahid P. Adherence interventions and outcomes of tuberculosis treatment: A systematic review and meta-analysis of trials and observational studies. PLoS Med 2018; 15:e1002595. [PMID: 29969463 PMCID: PMC6029765 DOI: 10.1371/journal.pmed.1002595] [Citation(s) in RCA: 215] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 05/29/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Incomplete adherence to tuberculosis (TB) treatment increases the risk of delayed culture conversion with continued transmission in the community, as well as treatment failure, relapse, and development or amplification of drug resistance. We conducted a systematic review and meta-analysis of adherence interventions, including directly observed therapy (DOT), to determine which approaches lead to improved TB treatment outcomes. METHODS AND FINDINGS We systematically reviewed Medline as well as the references of published review articles for relevant studies of adherence to multidrug treatment of both drug-susceptible and drug-resistant TB through February 3, 2018. We included randomized controlled trials (RCTs) as well as prospective and retrospective cohort studies (CSs) with an internal or external control group that evaluated any adherence intervention and conducted a meta-analysis of their impact on TB treatment outcomes. Our search identified 7,729 articles, of which 129 met the inclusion criteria for quantitative analysis. Seven adherence categories were identified, including DOT offered by different providers and at various locations, reminders and tracers, incentives and enablers, patient education, digital technologies (short message services [SMSs] via mobile phones and video-observed therapy [VOT]), staff education, and combinations of these interventions. When compared with DOT alone, self-administered therapy (SAT) was associated with lower rates of treatment success (CS: risk ratio [RR] 0.81, 95% CI 0.73-0.89; RCT: RR 0.94, 95% CI 0.89-0.98), adherence (CS: RR 0.83, 95% CI 0.75-0.93), and sputum smear conversion (RCT: RR 0.92, 95% CI 0.87-0.98) as well as higher rates of development of drug resistance (CS: RR 4.19, 95% CI 2.34-7.49). When compared to DOT provided by healthcare providers, DOT provided by family members was associated with a lower rate of adherence (CS: RR 0.86, 95% CI 0.79-0.94). DOT delivery in the community versus at the clinic was associated with a higher rate of treatment success (CS: RR 1.08, 95% CI 1.01-1.15) and sputum conversion at the end of two months (CS: RR 1.05, 95% CI 1.02-1.08) as well as lower rates of treatment failure (CS: RR 0.56, 95% CI 0.33-0.95) and loss to follow-up (CS: RR 0.63, 95% CI 0.40-0.98). Medication monitors improved adherence and treatment success and VOT was comparable with DOT. SMS reminders led to a higher treatment completion rate in one RCT and were associated with higher rates of cure and sputum conversion when used in combination with medication monitors. TB treatment outcomes improved when patient education, healthcare provider education, incentives and enablers, psychological interventions, reminders and tracers, or mobile digital technologies were employed. Our findings are limited by the heterogeneity of the included studies and lack of standardized research methodology on adherence interventions. CONCLUSION TB treatment outcomes are improved with the use of adherence interventions, such as patient education and counseling, incentives and enablers, psychological interventions, reminders and tracers, and digital health technologies. Trained healthcare providers as well as community delivery provides patient-centered DOT options that both enhance adherence and improve treatment outcomes as compared to unsupervised, SAT alone.
Collapse
Affiliation(s)
- Narges Alipanah
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General, San Francisco, California, United States of America
- Santa Clara Valley Medical Center, Department of Internal Medicine, San Jose, California, United States of America
| | - Leah Jarlsberg
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General, San Francisco, California, United States of America
| | - Cecily Miller
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General, San Francisco, California, United States of America
| | - Nguyen Nhat Linh
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Dennis Falzon
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | | | - Payam Nahid
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General, San Francisco, California, United States of America
| |
Collapse
|
10
|
O’Donovan J, O’Donovan C, Kuhn I, Sachs SE, Winters N. Ongoing training of community health workers in low-income andmiddle-income countries: a systematic scoping review of the literature. BMJ Open 2018; 8:e021467. [PMID: 29705769 PMCID: PMC5931295 DOI: 10.1136/bmjopen-2017-021467] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/06/2018] [Accepted: 04/10/2018] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Understanding the current landscape of ongoing training for community health workers (CHWs) in low-income and middle-income countries (LMICs) is important both for organisations responsible for their training, as well as researchers and policy makers. This scoping review explores this under-researched area by mapping the current delivery implementation and evaluation of ongoing training provision for CHWs in LMICs. DESIGN Systematic scoping review. DATA SOURCES MEDLINE, Embase, AMED, Global Health, Web of Science, Scopus, ASSIA, LILACS, BEI and ERIC. STUDY SELECTION Original studies focusing on the provision of ongoing training for CHWs working in a country defined as low income and middle income according to World Bank Group 2012 classification of economies. RESULTS The scoping review found 35 original studies that met the inclusion criteria. Ongoing training activities for CHWs were described as supervision (n=19), inservice or refresher training (n=13) or a mixture of both (n=3). Although the majority of studies emphasised the importance of providing ongoing training, several studies reported no impact of ongoing training on performance indicators. The majority of ongoing training was delivered inperson; however, four studies reported the use of mobile technologies to support training delivery. The outcomes from ongoing training activities were measured and reported in different ways, including changes in behaviour, attitudes and practice measured in a quantitative manner (n=16), knowledge and skills (n=6), qualitative assessments (n=5) or a mixed methods approach combining one of the aforementioned modalities (n=8). CONCLUSIONS This scoping review highlights the diverse range of ongoing training for CHWs in LMICs. Given the expansion of CHW programmes globally, more attention should be given to the design, delivery, monitoring and sustainability of ongoing training from a health systems strengthening perspective.
Collapse
Affiliation(s)
| | | | - Isla Kuhn
- Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Niall Winters
- Department of Education, University of Oxford, Oxford, UK
| |
Collapse
|
11
|
Broughton EI, Karamagi E, Kigonya A, Lawino A, Marquez L, Lunsford SS, Twinomugisha A. The cost-effectiveness of three methods of disseminating information to improve medical male circumcision in Uganda. PLoS One 2018; 13:e0195691. [PMID: 29672578 PMCID: PMC5908073 DOI: 10.1371/journal.pone.0195691] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 03/27/2018] [Indexed: 11/18/2022] Open
Abstract
Background Uganda is working to increase voluntary medical male circumcision (VMMC) to prevent HIV infection. To support VMMC quality improvement, this study compared three methods of disseminating information to facilities on how to improve VMMC quality: M—providing a written manual; MH—providing the manual plus a handover meeting in which clinicians shared advice on implementing key changes and participated in group discussion; and MHC—manual, handover meeting, and three site visits to the facility in which a coach provided individualized guidance and mentoring on improvement. We determined the different effects these had on compliance with indicators of quality of care. Methods This controlled pre-post intervention study randomized health facility groups to receive M, MH, or MHC. Observations of VMMCs performance determined compliance with quality indicators. Intervention costs per patient receiving VMMC were used in a decision-tree cost-effectiveness model to calculate the incremental cost per additional patient treated to compliance with indicators of informed consent, history taking, anesthesia administration, and post-operative instructions. Results The most intensive method (MHC) cost $28.83 per patient and produced the biggest gains in history taking (35% improvement), anesthesia administration (20% improvement), and post-operative instructions (37% improvement). The least intensive method (M; $1.13 per patient) was most efficient because it produced small gains for a very low cost. The handover meeting (MH) was the most expensive among the three interventions but did not have a corresponding positive effect on quality. Conclusion Health workers in facilities that received the VMMC improvement manual and participated in the handover meeting and coaching visits showed more improvement in VMMC quality indicators than those in the other two intervention groups. Providing the manual alone cost the least but was also the least effective in achieving improvements. The MHC intervention is recommended for broader implementation to improve VMMC quality in Uganda.
Collapse
Affiliation(s)
- Edward I. Broughton
- University Research Co., LLC, Chevy Chase, Maryland, United States of America
- USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, Chevy Chase, Maryland, United States of America
- International Health Department, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Esther Karamagi
- USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, Chevy Chase, Maryland, United States of America
- University Research Co., LLC, Kampala, Uganda
| | - Angella Kigonya
- USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, Chevy Chase, Maryland, United States of America
- University Research Co., LLC, Kampala, Uganda
| | - Anna Lawino
- USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, Chevy Chase, Maryland, United States of America
- University Research Co., LLC, Kampala, Uganda
| | - Lani Marquez
- University Research Co., LLC, Chevy Chase, Maryland, United States of America
- USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, Chevy Chase, Maryland, United States of America
| | - Sarah Smith Lunsford
- USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, Chevy Chase, Maryland, United States of America
- EnCompass, LLC, Rockville, Maryland, United States of America
| | - Albert Twinomugisha
- USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, Chevy Chase, Maryland, United States of America
- University Research Co., LLC, Kampala, Uganda
| |
Collapse
|
12
|
Andrade KVFD, Nery JS, Souza RAD, Pereira SM. Effects of social protection on tuberculosis treatment outcomes in low or middle-income and in high-burden countries: systematic review and meta-analysis. CAD SAUDE PUBLICA 2018; 34:e00153116. [DOI: 10.1590/0102-311x00153116] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/09/2017] [Indexed: 11/22/2022] Open
Abstract
Tuberculosis (TB) is a poverty infectious disease that affects millions of people worldwide. Evidences suggest that social protection strategies (SPS) can improve TB treatment outcomes. This study aimed to synthesize such evidences through systematic literature review and meta-analysis. We searched for studies conducted in low- or middle-income and in high TB-burden countries, published during 1995-2016. The review was performed by searching PubMed/MEDLINE, Scopus, Web of Science, ScienceDirect and LILACS. We included only studies that investigated the effects of SPS on TB treatment outcomes. We retained 25 studies for qualitative synthesis. Meta-analyses were performed with 9 randomized controlled trials, including a total of 1,687 participants. Pooled results showed that SPS was associated with TB treatment success (RR = 1.09; 95%CI: 1.03-1.14), cure of TB patients (RR = 1.11; 95%CI: 1.01-1.22) and with reduction in risk of TB treatment default (RR = 0.63; 95%CI: 0.45-0.89). We did not detect effects of SPS on the outcomes treatment failure and death. These findings revealed that SPS might improve TB treatment outcomes in lower-middle-income economies or countries with high burden of this disease. However, the overall quality of evidences regarding these effect estimates is low and further well-conducted randomized studies are needed.
Collapse
|
13
|
Abdel-All M, Putica B, Praveen D, Abimbola S, Joshi R. Effectiveness of community health worker training programmes for cardiovascular disease management in low-income and middle-income countries: a systematic review. BMJ Open 2017; 7:e015529. [PMID: 29101131 PMCID: PMC5695434 DOI: 10.1136/bmjopen-2016-015529] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Community health workers (CHWs) are increasingly being tasked to prevent and manage cardiovascular disease (CVD) and its risk factors in underserved populations in low-income and middle-income countries (LMICs); however, little is known about the required training necessary for them to accomplish their role. This review aimed to evaluate the training of CHWs for the prevention and management of CVD and its risk factors in LMICs. METHODS A search strategy was developed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and five electronic databases (Medline, Global Health, ERIC, EMBASE and CINAHL) were searched to identify peer-reviewed studies published until December 2016 on the training of CHWs for prevention or control of CVD and its risk factors in LMICs. Study characteristics were extracted using a Microsoft Excel spreadsheet and quality assessed using Effective Public Health Practice Project's Quality Assessment Tool. The search, data extraction and quality assessment were performed independently by two researchers. RESULTS The search generated 928 articles of which 8 were included in the review. One study was a randomised controlled trial, while the remaining were before-after intervention studies. The training methods included classroom lectures, interactive lessons, e-learning and online support and group discussions or a mix of two or more. All the studies showed improved knowledge level post-training, and two studies demonstrated knowledge retention 6 months after the intervention. CONCLUSION The results of the eight included studies suggest that CHWs can be trained effectively for CVD prevention and management. However, the effectiveness of CHW trainings would likely vary depending on context given the differences between studies (eg, CHW demographics, settings and training programmes) and the weak quality of six of the eight studies. Well-conducted mixed-methods studies are needed to provide reliable evidence about the effectiveness and cost-effectiveness of training programmes for CHWs.
Collapse
Affiliation(s)
- Marwa Abdel-All
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Barbara Putica
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | | | - Seye Abimbola
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Rohina Joshi
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| |
Collapse
|
14
|
Wu S, Roychowdhury I, Khan M. Evaluations of training programs to improve human resource capacity for HIV, malaria, and TB control: a systematic scoping review of methods applied and outcomes assessed. Trop Med Health 2017; 45:16. [PMID: 28680324 PMCID: PMC5493875 DOI: 10.1186/s41182-017-0056-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/16/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Owing to the global health workforce crisis, more funding has been invested in strengthening human resources for health, particularly for HIV, tuberculosis, and malaria control; however, little is known about how these investments in training are evaluated. This paper examines how frequently HIV, malaria, and TB healthcare provider training programs have been scientifically evaluated, synthesizes information on the methods and outcome indicators used, and identifies evidence gaps for future evaluations to address. METHODS We conducted a systematic scoping review of publications evaluating postgraduate training programs, including in-service training programs, for HIV, tuberculosis, and malaria healthcare providers between 2000 and 2016. Using broad inclusion criteria, we searched three electronic databases and additional gray literature sources. After independent screening by two authors, data about the year, location, methodology, and outcomes assessed was extracted from eligible training program evaluation studies. Training outcomes evaluated were categorized into four levels (reaction, learning, behavior, and results) based on the Kirkpatrick model. FINDINGS Of 1473 unique publications identified, 87 were eligible for inclusion in the analysis. The number of published articles increased after 2006, with most (n = 57, 66%) conducted in African countries. The majority of training evaluations (n = 44, 51%) were based on HIV with fewer studies focused on malaria (n = 28, 32%) and TB (n = 23, 26%) related training. We found that quantitative survey of trainees was the most commonly used evaluation method (n = 29, 33%) and the most commonly assessed outcomes were knowledge acquisition (learning) of trainees (n = 44, 51%) and organizational impacts of the training programs (38, 44%). Behavior change and trainees' reaction to the training were evaluated less frequently and using less robust methods; costs of training were also rarely assessed. CONCLUSIONS Our study found that a limited number of robust evaluations had been conducted since 2000, even though the number of training programs has increased over this period to address the human resource shortage for HIV, malaria, and TB control. Specifically, we identified a lack evaluation studies on TB- and malaria-related healthcare provider training and very few studies assessing behavior change of trainees or costs of training. Developing frameworks and standardized evaluation methods may facilitate strengthening of the evidence base to inform policies on and investments in training programs.
Collapse
Affiliation(s)
- Shishi Wu
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore
| | - Imara Roychowdhury
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore
| | - Mishal Khan
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore.,Communicable Diseases Policy Research Group, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT United Kingdom
| |
Collapse
|
15
|
Banda H, Robinson R, Thomson R, Squire SB, Mortimer K. The 'Practical Approach to Lung Health' in sub-Saharan Africa: a systematic review. Int J Tuberc Lung Dis 2017; 20:552-9. [PMID: 26970167 PMCID: PMC4784471 DOI: 10.5588/ijtld.15.0613] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
SETTING: There is a high burden of respiratory disease in sub-Saharan Africa. To address this problem, the World Health Organization launched the ‘Practical approach to Lung Health’ (PAL), i.e., locally applicable integrated syndromic algorithms, to improve primary care management of these diseases. OBJECTIVE: To examine the evidence for the impact of PAL on the diagnosis and management of tuberculosis (TB) and other common respiratory problems in sub-Saharan Africa. DESIGN: A systematic review of MEDLINE (1998–2015), EMBASE (1998–2015) and CINAHL (1998–2015) was conducted to find trials evaluating PAL implementation in sub-Saharan Africa. RESULTS: Five studies were found, evaluating three PAL variations: PAL in South Africa (PALSA), PALSA with integrated human immunodeficiency virus treatment (PALSA PLUS) and PAL in Malawi using lay health workers (PALM/LHW). PALSA increased TB diagnosis (OR 1.72, 95%CI 1.04–2.85), as did PALSA PLUS (OR 1.25, 95%CI 1.01–1.55). Cure or completion rates in retreatment cases in PALSA and PALSA PLUS were significantly improved (OR 1.78, 95%CI 1.13–2.76). PALM/LHW, which examined TB treatment success, found no significant improvement (P = 0.578). CONCLUSION: The limited research performed shows that PAL can be effective in TB diagnosis and partial treatment success; however, more evidence is needed to assess its effects on other respiratory diseases, especially in wider sub-Saharan Africa.
Collapse
Affiliation(s)
- H Banda
- Research for Equity and Community Health Trust, Lilongwe, Malawi
| | - R Robinson
- Department of Clinical Sciences and Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Liverpool, UK
| | - R Thomson
- Department of Clinical Sciences and Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Liverpool, UK
| | - S B Squire
- Department of Clinical Sciences and Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Liverpool, UK
| | - K Mortimer
- Department of Clinical Sciences and Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
16
|
Evaluating the impact of healthcare provider training to improve tuberculosis management: a systematic review of methods and outcome indicators used. Int J Infect Dis 2016; 56:105-110. [PMID: 27979785 DOI: 10.1016/j.ijid.2016.11.421] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/26/2016] [Accepted: 11/29/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Developing human resources capacity is vital for tuberculosis (TB) control in low- and middle-income countries. Although investments in TB healthcare provider (HCP) training programmes have increased, it is unclear whether these are robustly evaluated. The objective of this systematic review was to synthesize the methods and outcome indicators used to assess TB HCP training programmes. METHODS A systematic scoping review of publications reporting on evaluations of training programmes for TB HCPs - including doctors, nurses, paramedics, and lay health workers - was conducted through a search in three electronic databases, Google Scholar, and five websites of non-profit organizations. Data on the study location, population trained, outcomes assessed, and evaluation approach were extracted. RESULTS After screening 499 unique publications, 21 were eligible for inclusion in the analysis. The majority of evaluations were conducted in Africa. The most common evaluation methods were a review of patient records (n=8, 38%) and post-training interview with trainees (n=7, 33%). In terms of outcomes, more than half of the studies (n=12, 57%) evaluated knowledge acquisition of trainees, with only six (29%) assessing on-the-job behaviour change. CONCLUSIONS Even though more funds have been invested in TB HCP training, publications from robust evaluations assessing the impact on quality of care and behaviour change are limited.
Collapse
|
17
|
Puchalski Ritchie LM, van Lettow M, Makwakwa A, Chan AK, Hamid JS, Kawonga H, Martiniuk ALC, Schull MJ, van Schoor V, Zwarenstein M, Barnsley J, Straus SE. The impact of a knowledge translation intervention employing educational outreach and a point-of-care reminder tool vs standard lay health worker training on tuberculosis treatment completion rates: study protocol for a cluster randomized controlled trial. Trials 2016; 17:439. [PMID: 27604571 PMCID: PMC5015212 DOI: 10.1186/s13063-016-1563-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/19/2016] [Indexed: 11/29/2022] Open
Abstract
Background Despite availability of effective treatment, tuberculosis (TB) remains an important cause of morbidity and mortality globally, with low- and middle-income countries most affected. In many such settings, including Malawi, the high burden of disease and severe shortage of skilled healthcare workers has led to task-shifting of outpatient TB care to lay health workers (LHWs). LHWs improve access to healthcare and some outcomes, including TB completion rates, but lack of training and supervision limit their impact. The goals of this study are to improve TB care provided by LHWs in Malawi by refining, implementing, and evaluating a knowledge translation strategy designed to address a recognized gap in LHWs’ TB and job-specific knowledge and, through this, to improve patient outcomes. Methods/design We are employing a mixed-methods design that includes a pragmatic cluster randomized controlled trial and a process evaluation using qualitative methods. Trial participants will include all health centers providing TB care in four districts in the South East Zone of Malawi. The intervention employs educational outreach, a point-of-care reminder tool, and a peer support network. The primary outcome is proportion of treatment successes, defined as the total of TB patients cured or completing treatment, with outcomes taken from Ministry of Health treatment records. With an alpha of 0.05, power of 0.80, a baseline treatment success of 0.80, intraclass correlation coefficient of 0.1 based on our pilot study, and an estimated 100 clusters (health centers providing TB care), a minimum of 6 patients per cluster is required to detect a clinically significant 0.10 increase in the proportion of treatment successes. Our process evaluation will include interviews with LHWs and patients, and a document analysis of LHW training logs, quarterly peer trainer meetings, and mentorship meeting notes. An estimated 10–15 LHWs and 10–15 patients will be required to reach saturation in each of 2 planned interview periods, for a total of 40–60 interview participants. Discussion This study will directly inform the efforts of knowledge users within TB care and, through extension of the approach, other areas of care provided by LHWs in Malawi and other low- and middle-income countries. Trial registration ClinicalTrials.gov NCT02533089. Registered 20 August 2015. Protocol Date/Version 29 May 2016/Version 2. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1563-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Lisa M Puchalski Ritchie
- Department of Medicine, University of Toronto, Toronto, ON, Canada. .,Department of Emergency Medicine, University Health Network, Toronto, ON, Canada. .,Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
| | - Monique van Lettow
- Dignitas International, P.O. Box 1071, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Austine Makwakwa
- National Tuberculosis Control Program, Ministry of Health, P.O. Box 30377, Lilongwe, Malawi
| | - Adrienne K Chan
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Center, Toronto, ON, Canada.,Dignitas International, 550 Queen Street East, Suite 335, Toronto, ON, Canada
| | - Jemila S Hamid
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Harry Kawonga
- Dignitas International, P.O. Box 1071, Zomba, Malawi
| | - Alexandra L C Martiniuk
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Dignitas International, 550 Queen Street East, Suite 335, Toronto, ON, Canada.,George Institute for Global Health, Sydney, Australia.,The University of Sydney, Sydney, Australia
| | - Michael J Schull
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Center, Toronto, ON, Canada.,Dignitas International, 550 Queen Street East, Suite 335, Toronto, ON, Canada
| | | | - Merrick Zwarenstein
- Department of Family Medicine, Western University, London, ON, Canada.,Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, 1151 Richmond Street, London, ON, N6A 5C1, Canada
| | - Jan Barnsley
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 55 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada
| | - Sharon E Straus
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| |
Collapse
|
18
|
Puchalski Ritchie LM, van Lettow M, Barnsley J, Chan AK, Schull MJ, Martiniuk ALC, Makwakwa A, Zwarenstein M. Lay Health Workers experience of a tailored knowledge translation intervention to improve job skills and knowledge: a qualitative study in Zomba district Malawi. BMC MEDICAL EDUCATION 2016; 16:54. [PMID: 26861834 PMCID: PMC4748491 DOI: 10.1186/s12909-016-0580-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 02/04/2016] [Indexed: 05/09/2023]
Abstract
BACKGROUND Like many sub-Saharan African countries, Malawi is facing a critical shortage of skilled healthcare workers. In response to this crisis, a formal cadre of lay health workers (LHW) has been established and now carries out several basic health care services, including outpatient TB care and adherence support. While ongoing training and supervision are recognized as essential to the effectiveness of LHW programs, information is lacking as to how these needs are best addressed. The objective of this qualitative study was to explore LHWs responses to a tailored knowledge translation intervention they received, designed to address a previously identified training and knowledge gap. METHODS Forty-five interviews were conducted with 36 healthcare workers. Fourteen to sixteen interviews were done at each of 3 evenly spaced time blocks over a one year period, with 6 individuals interviewed more than once to assess for change both within and across individuals overtime. RESULTS Reported benefits of the intervention included: increased TB, HIV, and job-specific knowledge; improved clinical skills; and increased confidence and satisfaction with their work. Suggestions for improvement were less consistent across participants, but included: increasing the duration of the training, changing to an off-site venue, providing stipends or refreshments as incentives, and adding HIV and drug dosing content. CONCLUSIONS Despite the significant departure of the study intervention from the traditional approach to training employed in Malawi, the intervention was well received and highly valued by LHW participants. Given the relative low-cost and flexibility of the methods employed, this appears a promising approach to addressing the training needs of LHW programs, particularly in Low- and Middle-income countries where resources are most constrained.
Collapse
Affiliation(s)
- Lisa M Puchalski Ritchie
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi.
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
| | - Jan Barnsley
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - Adrienne K Chan
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
- Dignitas International, Toronto, Canada.
- Sunnybrook Health Sciences Center, Toronto, ON, Canada.
| | - Michael J Schull
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Dignitas International, Toronto, Canada.
- Sunnybrook Health Sciences Center, Toronto, ON, Canada.
| | - Alexandra L C Martiniuk
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
- Dignitas International, Toronto, Canada.
- George Institute for Global Health, Sydney, Australia.
- The University of Sydney, Sydney, Australia.
| | - Austine Makwakwa
- National TB Control Program, Ministry of Health, Lilongwe, Malawi.
| | - Merrick Zwarenstein
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
- Knowledge translation unit, Lung Institute, University of Cape Town, Cape Town, South Africa.
- Stellenbosch University Faculty of Health Sciences, Tygerberg, South Africa.
- Department of Family Medicine, Western University, London, ON, Canada.
| |
Collapse
|