Bridging the knowledge-practice gap in tuberculosis contact management in a high-burden setting: a mixed-methods protocol for a multicenter health system strengthening study

Screening for latent tuberculosis in migrants-status quo and future challenges

OBJECTIVES

To review the evidence that migrants from tuberculosis (TB) high-incidence countries migrating to TB low-incidence countries significantly contribute to active TB cases in the counties of destination, primarily through reactivation of latent TB.

METHODS

This is a narrative review. The different screening programs in the countries of destination are reviewed either based on screening and preventive treatment of latent TB pre or more commonly - post arrival.

RESULTS

Screening can be performed using interferon-gamma release assays (IGRA) or tuberculin skin tests (TST). Preventive treatment of latent TB is using either monotherapy with isoniazid, or in combination with rifampicin or rifapentine. We discuss the ethical issues of preventive treatment in asymptomatic individuals and how these are addressed in different screening programs.

CONCLUSION

Screening migrants from TB high endemic countries to TB low endemic countries is beneficial. There is a lack of standardization and agreement on screening protocols, follow up and treatment.

Community-based Advocacy Communication Social Mobilization (ACSM) intervention by empowering key community leaders: Evaluation using the RE-AIM framework

Background

Based on the theme of World Tuberculosis (TB) Day 2018-"Wanted Leaders for TB free world," various studies and country-level project have witnessed how training leaders on TB has helped enhance TB awareness in the community. This study was conducted to evaluate the effectiveness of Advocacy Communication and Social Mobilization (ACSM) intervention strategy through key community leaders, using Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

Materials and Methods

This study was undertaken by the Department of Community Medicine, Sri Manakula Vinayagar Medical College and Hospital (SMVMCH), Puducherry, in the field practice area of Primary Health Centre (PHC), Thirubuvanai. The STOP TB, ENGAGE-TB, and National TB Elimination Program (NTEP) guidelines were used for interventions. Key community leaders (KCL) list (N = 117) was obtained from Mannadipet commune panchayat and PHC. The study was conducted in four phases: phase 1 (baseline): quantitative data: proportion of presumptive TB cases from notification register; phase 2 (intervention): training program for staff nurses, auxiliary nurse midwife (ANM), Accredited Social Health Activist (ASHA), and Anganwadi workers (group activity), participatory rural appraisal (PRA) activity for self-help group (SHG) leaders, and health education session for religious leaders and ex-panchayat leaders; phase 3: strengthening of ongoing activity: health education session and active case finding for TB; and phase 4: end line: outcome of the intervention, evaluated using the RE-AIM framework.

Results

As an outcome of the intervention, there was a marginal increase (21 cases) in the proportion of presumptive TB cases when comparing before (2018) and after (2019) intervention. The proportion of presumptive TB cases identified and referred by KCL was 312. A total of 77 presumptive TB cases were identified through community-based active case finding (ACF). Two sputum samples (on the spot early morning) were collected and sent for Cartridge-based nucleic acid amplification testing (CBNAAT), of which three cases were positive.

Conclusion

This study was community led and involved leaders from diverse backgrounds, optimizing the chance of success. For sustainability, we have initiated TB support group.

Bridging the Gap: A Strategic Approach to Upscale Knowledge Among Diverse Healthcare Providers for Effective Tuberculosis Management in Gujarat, India

INTRODUCTION

Tuberculosis (TB) remains a global health challenge, particularly in low- and middle-income countries. Knowledge gaps among healthcare providers (HCPs) significantly impact TB management, hindering timely care-seeking and effective interventions.

OBJECTIVE

The primary objective was to assess knowledge gaps among 3086 HCPs engaged in the National Tuberculosis Elimination Program (NTEP) implementation in Gujarat, India. The study provided a platform to develop and implement cadre-specific training modules to address identified knowledge deficiencies and enhance TB management.

METHODOLOGY

The study was conducted in two phases. Phase one was designed as a cross-sectional assessment to identify the knowledge gaps. Phase two involved the development of cadre-specific training modules based on identified deficiencies in the knowledge, crafted with collaboration from an expert panel. The training impact will be evaluated after completion of the training of all cadres through a comprehensive assessment.

RESULTS

Out of 3086 assessed HCPs, 26% scored below the passing benchmark, revealing significant knowledge gaps. The variations were observed among and within the same cadres, with the accredited social health activists (ASHAs) and community health workers showing higher proficiency while pharmacists and medical officers showed lower proficiency. The cadre-specific training modules and training cascade were designed to address these gaps and improve TB-related knowledge and skills.

CONCLUSION

The study underscores the critical need for targeted interventions to address knowledge gaps among HCPs involved in TB control. The customized HCP-specific training programs are recommended to enhance knowledge, improve TB management, and contribute to national TB elimination goals.

Using the RE-AIM framework to evaluate the implementation and effectiveness of a WHO HEARTS-based intervention to integrate the management of hypertension into HIV care in Uganda: a process evaluation

BACKGROUND

World Health Organization (WHO) HEARTS packages are increasingly used to control hypertension. However, their feasibility in persons living with HIV (PLHIV) is unknown. We studied the effectiveness and implementation of a WHO HEARTS intervention to integrate the management of hypertension into HIV care.

METHODS

This was a mixed methods study at Uganda's largest HIV clinic. Components of the adapted WHO HEARTS intervention were lifestyle counseling, free hypertension medications, hypertension treatment protocol, task shifting, and monitoring tools. We determined the effectiveness of the intervention among PLHIV by comparing hypertension and HIV outcomes at baseline and 21 months. The RE-AIM framework was used to evaluate the implementation outcomes of the intervention at 21 months. We conducted four focus group discussions with PLHIV (n = 42), in-depth interviews with PLHIV (n = 9), healthcare providers (n = 15), and Ministry of Health (MoH) policymakers (n = 2).

RESULTS

Reach: Among the 15,953 adult PLHIV in the clinic, of whom 3892 (24%) had been diagnosed with hypertension, 1133(29%) initiated integrated hypertension-HIV treatment compared to 39 (1%) at baseline. Among the enrolled patients, the mean age was 51.5 ± 9.7 years and 679 (62.6%) were female.

EFFECTIVENESS

Among the treated patients, hypertension control improved from 9 to 72% (p < 0.001), mean systolic blood pressure (BP) from 153.2 ± 21.4 to 129.2 ± 15.2 mmHg (p < 0.001), and mean diastolic BP from 98.5 ± 13.5 to 85.1 ± 9.7 mmHg (p < 0.001). Overall, 1087 (95.9%) of patients were retained by month 21. HIV viral suppression remained high, 99.3 to 99.5% (p = 0.694). Patients who received integrated hypertension-HIV care felt healthy and saved more money. Adoption: All 48 (100%) healthcare providers in the clinic were trained and adopted the intervention. Training healthcare providers on WHO HEARTS, task shifting, and synchronizing clinic appointments for hypertension and HIV promoted adoption.

IMPLEMENTATION

WHO HEARTS intervention was feasible and implemented with fidelity. Maintenance: Leveraging HIV program resources and adopting WHO HEARTS protocols into national guidelines will promote sustainability.

CONCLUSIONS

The WHO HEARTS intervention promoted the integration of hypertension management into HIV care in the real-world setting. It was acceptable, feasible, and effective in controlling hypertension and maintaining optimal viral suppression among PLHIV. Integrating this intervention into national guidelines will promote sustainability.

Improving outcomes for hospitalised First Nations peoples though greater cultural safety and better communication: the Communicate Study Partnership study protocol

BACKGROUND

The Communicate Study is a partnership project which aims to transform the culture of healthcare systems to achieve excellence in culturally safe care for First Nations people. It responds to the ongoing impact of colonisation which results in First Nations peoples experiencing adverse outcomes of hospitalisation in Australia's Northern Territory. In this setting, the majority of healthcare users are First Nations peoples, but the majority of healthcare providers are not. Our hypotheses are that strategies to ensure cultural safety can be effectively taught, systems can become culturally safe and that the provision of culturally safe healthcare in first languages will improve experiences and outcomes of hospitalisation.

METHODS

We will implement a multicomponent intervention at three hospitals over 4 years. The main intervention components are as follows: cultural safety training called 'Ask the Specialist Plus' which incorporates a locally developed, purpose-built podcast, developing a community of practice in cultural safety and improving access to and uptake of Aboriginal language interpreters. Intervention components are informed by the 'behaviour change wheel' and address a supply-demand model for interpreters. The philosophical underpinnings are critical race theory, Freirean pedagogy and cultural safety. There are co-primary qualitative and quantitative outcome measures: cultural safety, as experienced by First Nations peoples at participating hospitals, and proportion of admitted First Nations patients who self-discharge. Qualitative measures of patient and provider experience, and patient-provider interactions, will be examined through interviews and observational data. Quantitative outcomes (documentation of language, uptake of interpreters (booked and completed), proportion of admissions ending in self-discharge, unplanned readmission, hospital length of stay, costs and cost benefits of interpreter use) will be measured using time-series analysis. Continuous quality improvement will use data in a participatory way to motivate change. Programme evaluation will assess Reach, Effectiveness, Adoption, Implementation and Maintenance ('RE-AIM').

DISCUSSION

The intervention components are innovative, sustainable and have been successfully piloted. Refinement and scale-up through this project have the potential to transform First Nations patients' experiences of care and health outcomes.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov Protocol Record 2008644.

The development of the national tuberculosis research priority in Indonesia: A comprehensive mixed-method approach

Ranked second in global tuberculosis (TB) incidence, Indonesia has developed a National Strategy for TB Prevention and Control 2020-2024 to accelerate the TB elimination program. Research and innovation are key pillars to support the program and need to be prioritised. This study aimed to develop updated national TB research priorities in Indonesia. This study was a mixed-methods study consisting of an open survey, a published literature survey, and Delphi survey. The open survey invited all related TB stakeholders to answer (a) the main barriers of the TB program and (b) the need for studies to support TB elimination. The published literature survey retrieved scientific articles published in national and international journals between 2015 and 2020 to identify gaps between published research and the current national strategy for TB control. The online survey and literature survey informed a panel of TB experts in a two-phase Delphi Survey to select the top 10 priority research topics. We identified 322 articles and analysed 1143 open survey responses. Through two-phases Delphi surveys, top ten research categories were listed: early TB detection; diagnosis and treatment of DR-TB; contact investigation; case detection and treatment of child TB; TB preventive therapy; government policy; laboratory for drug-sensitive- and drug-resistant-TB diagnosis; treatment adherence; diagnostic tool development; and community empowerment. This study also found the gap between stakeholders' interests and the importance of translating research into policy and practice. TB research priorities have been identified through the involvement of various stakeholders. The combination of an online survey, a published literature survey, and a Delphi survey was a rigorous methodology and was fit to build a systematic consensus about the priority of TB research.

Implementation, interrupted: Identifying and leveraging factors that sustain after a programme interruption

Many implementation efforts experience interruptions, especially in settings with developing health systems. Approaches for evaluating interruptions are needed to inform re-implementation strategies. We sought to devise an approach for evaluating interruptions by exploring the sustainability of a programme that implemented diabetes mellitus (DM) screening within tuberculosis clinics in Uganda in 2017. In 2019, we conducted nine interviews with clinic staff and observed clinic visits to determine their views and practices on providing integrated care. We mapped themes to a social ecological model with three levels derived from the Consolidated Framework for Implementation Research (CFIR): outer setting (i.e. community), inner setting (i.e. clinic), and individuals (i.e. clinicians). Respondents explained that DM screening ceased due to disruptions in the national supply chain for glucose test strips, which had cascading effects on clinics and clinicians. Lack of screening supplies in clinics limited clinicians' opportunities to perform DM screening, which contributed to diminished self-efficacy. However, culture, compatibility and clinicians' beliefs about DM screening sustained throughout the interruption. We propose an approach for evaluating interruptions using the CFIR and social ecological model; other programmes can adapt this approach to identify cascading effects of interruptions and target them for re-implementation.

Priority Activities in Child and Adolescent Tuberculosis to Close the Policy-Practice Gap in Low- and Middle-Income Countries

Over the past 15 years, and despite many difficulties, significant progress has been made to advance child and adolescent tuberculosis (TB) care. Despite increasing availability of safe and effective treatment and prevention options, TB remains a global health priority as a major cause of child and adolescent morbidity and mortality—over one and a half million children and adolescents develop TB each year. A history of the global public health perspective on child and adolescent TB is followed by 12 narratives detailing challenges and progress in 19 TB endemic low and middle-income countries. Overarching challenges include: under-detection and under-reporting of child and adolescent TB; poor implementation and reporting of contact investigation and TB preventive treatment services; the need for health systems strengthening to deliver effective, decentralized services; and lack of integration between TB programs and child health services. The COVID-19 pandemic has had a significant negative impact on case detection and treatment outcomes. Child and adolescent TB working groups can address country-specific challenges to close the policy–practice gaps by developing and supporting decentral ized models of care, strengthening clinical and laboratory diagnosis, including of multidrug-resistant TB, providing recommended options for treatment of disease and infection, and forging strong collaborations across relevant health sectors.

Factors Affecting Continued Participation in Tuberculosis Contact Investigation in a Low-Income, High-Burden Setting

SETTING

Outpatient clinics, Kota Kinabalu, Malaysia; January-April 2018.

OBJECTIVES

To identify barriers to full participation in tuberculosis (TB) contact investigation.

METHODS

Cross-sectional study of knowledge, perceptions, and behaviours among TB contacts. This study was conducted among contacts who attended an initial clinic visit to explore retention in care. During this first visit, contacts were approached for participation in a questionnaire at a follow-up visit. Contacts who consented but did not subsequently attend were interviewed at home. Associations between questionnaire findings and attendance were tested using logistic regression.

RESULTS

Of the total 1436 identified contacts, 800 (56%) attended an initial clinic visit. Of 237 consenting TB contacts, 207 (87%) attended their follow-up appointment. In univariable analyses, the odds of attendance were highest for people notified to attend the TB clinic directly by a health inspector; close relatives of TB patients; non-students; people with higher incomes and smaller households; older individuals; males; and people not perceiving TB as stigmatising. In multivariable analysis, mode of notification to attend and having a close relative with TB remained significant.

CONCLUSIONS

Health inspectors provide an effective role in TB contact investigation through direct personal communication to encourage the completion of the TB screening process, but this requires further integration with clinical processes, and with workplace and school-based investigations.

Tuberculosis: yesterday, today and tomorrow

Tuberculosis (TB) remains an important public health challenge globally and in Australia. For the more than 10 million people who become sick with TB each year, the disease can cause immense personal and economic hardship, including loss of income and education through ill health, prolonged and arduous treatment, and stigmatisation – perpetuating a cycle of disadvantage. Past efforts to control TB have taught us much about modern disease control and public health. As the world grapples with the coronavirus (COVID-19) pandemic, the response to TB provides valuable lessons which can inform our response to COVID-19.

Training for Tuberculosis Elimination in Indonesia: Achievements, Reflections, and Potential for Impact

Indonesia has the third highest tuberculosis (TB) caseload internationally. A cornerstone for strengthening health systems to respond to TB is a well-trained workforce. In a partnership between Indonesian and Australian institutions, TB training was run during 2018 to strengthen the local capacity to meet End TB strategy targets. This paper aims to report on course design, delivery, training outcomes, and reflections. Seventy-six Indonesian healthcare workers, program staff, researchers, and policy-makers were selected from over 800 applicants. The structure comprised three trainings, each with a pre-course workshop (in Indonesia) to identify learning needs, a two-week block (Australia), and a post-course workshop (Indonesia). The training content delivered was a combination of TB technical knowledge and program/project theory, design, and logic, and the training utilised multiple teaching and learning methods. An innovative element of the training was participant-designed TB workplace projects focusing on context-specific priorities. Evaluation was undertaken using participant surveys and appraisal of the projects. Participants rated the course highly, while success in project implementation varied. Reflections include the importance of involving Indonesian experts in delivery of training, the need to understand participant learning requirements and adapt the training content accordingly, and the challenge of measuring tangible training outputs.