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Teibo TKA, Andrade RLDP, Rosa RJ, de Abreu PD, Olayemi OA, Alves YM, Vaz Tavares RB, da Costa FBP, Dias Moura HS, Ferezin L, Tártaro AF, de Campos MT, Ribeiro NM, Berra TZ, Arcêncio RA. Barriers That Interfere with Access to Tuberculosis Diagnosis and Treatment across Countries Globally: A Systematic Review. ACS Infect Dis 2024; 10:2600-2614. [PMID: 39023509 PMCID: PMC11320565 DOI: 10.1021/acsinfecdis.4c00466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Revised: 07/08/2024] [Accepted: 07/10/2024] [Indexed: 07/20/2024]
Abstract
This study evaluated the barriers that interfere with access to diagnosis and treatment of tuberculosis (TB) from the perspective of the patient and health professionals globally. Using the PICo acronym, the question we asked was "What are the barriers that interfere with access to tuberculosis diagnosis and treatment (I) from the perspective of patients and/or health professionals (P) across countries globally (Co)?". We searched the following databases: EMBASE, Scopus, MEDLINE, Latin American and Caribbean Literature in Health Sciences (LILACS), and Web of Science. On Rayyan, duplicates were removed and extraction was done afterward by two authors independently, followed by a tiebreaker. Using a Critical Appraisal Tool proposed by the Joanna Briggs Institute, the methodological quality of the article was assessed. From 36 published articles, the barriers to tuberculosis diagnosis as obtained from our study include information scarcity/low TB knowledge, exorbitant cost of transport, sample collection challenges, long distance to health facility, gender limitations, lack of decentralized diagnostic services, payment for diagnosis and testing, medication side effects, multiple visits during therapy, delayed diagnosis, poor human resources, low knowledge of medical practitioners, concerns regarding the efficacy of treatment, poor facility coordination, poor socioeconomic factors, fear and stigmatization of TB, and wrong initial diagnosis. The review of studies on TB diagnosis and treatment barriers evidences the diverse barriers to the eradication of tuberculosis. Eliminating these barriers is an onus that lies on policy makers, citizens, and health workers alike, with the joint aim of reducing the global TB burden.
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Affiliation(s)
- Titilade Kehinde Ayandeyi Teibo
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
| | - Rubia Laine de Paula Andrade
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
| | - Rander Junior Rosa
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
- Department
of Physiology, Obafemi Awolowo University, Ile-Ife, Osun State 220282, Nigeria
| | - Paula Daniella de Abreu
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
| | | | - Yan Mathias Alves
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
| | - Reginaldo Bazon Vaz Tavares
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
| | - Fernanda Bruzadelli Paulino da Costa
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
- Department
of Physiology, Obafemi Awolowo University, Ile-Ife, Osun State 220282, Nigeria
| | - Heriederson Sávio Dias Moura
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
| | - Letícia
Perticarrara Ferezin
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
- Department
of Physiology, Obafemi Awolowo University, Ile-Ife, Osun State 220282, Nigeria
| | - Ariela Fehr Tártaro
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
| | - Mônica
Chiodi Toscano de Campos
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
| | - Natacha Martins Ribeiro
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
| | - Thaís Zamboni Berra
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
| | - Ricardo Alexandre Arcêncio
- Department
of Maternal-Infant and Public Health Nursing, Ribeirão Preto
College of Nursing, University of São
Paulo, Ribeirão
Preto, São Paulo 14040-092, Brazil
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Kamchedzera W, Quaife M, Msukwa-Panje W, Burke RM, Macpherson L, Kumwenda M, Twabi HH, Quartagno M, MacPherson P, Esmail H. Treatment preferences among people at risk of developing tuberculosis: A discrete choice experiment. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002804. [PMID: 39028696 PMCID: PMC11259259 DOI: 10.1371/journal.pgph.0002804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/01/2024] [Indexed: 07/21/2024]
Abstract
Diagnosing and treating people with bacteriologically-negative but radiologically-apparent tuberculosis (TB) may contribute to more effective TB care and reduce transmission. However, optimal treatment approaches for this group are unknown. It is important to understand peoples' preferences of treatment options for effective programmatic implementation of people-centred treatment approaches. We designed and implemented a discrete choice experiment (DCE) to solicit treatment preferences among adults (≥18 years) with TB symptoms attending a primary health clinic in Blantyre, Malawi. Treatment attributes included in the DCE were as follows: duration of treatment; number of tablets per dose; reduction in the risk of being unwell with TB disease; likelihood of infecting others; adverse effects from the treatment; frequency of follow up; and the annual travel cost to access care. Quantitative choice modelling with multinomial logit models estimated through frequentist and Bayesian approaches investigated preferences for the management of bacteriologically-negative, but radiographically-apparent TB. 128 participants were recruited (57% male, 43.8% HIV-positive, 8.6% previously treated for TB). Participants preferred to take any treatment compared to not taking treatment (odds ratio [OR] 5.78; 95% confidence interval [CI]: 2.40, 13.90). Treatments that reduced the relative risk of developing TB disease by 80% were preferred (OR: 2.97; 95% CI: 2.09, 4.21) compared to treatments that lead to a lower reduction in risk of 50%. However, there was no evidence for treatments that are 95% effective being preferred over those that are 80% effective. Participants strongly favoured the treatments that could completely stop transmission (OR: 7.87, 95% CI: 5.71, 10.84), and prioritised avoiding side effects (OR: 0.19, 95% CI: 0.12, 0.29). There was no evidence of an interaction between perceived TB disease risk and treatment preferences. In summary, participants were primarily concerned with the effectiveness of TB treatments and strongly preferred treatments that removed the risk of onward transmission. Person-centred approaches of preferences for treatment should be considered when designing new treatment strategies. Understanding treatment preferences will ensure that any recommended treatment for probable early TB disease is well accepted and utilized by the public.
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Affiliation(s)
- Wala Kamchedzera
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Matthew Quaife
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Wezi Msukwa-Panje
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Rachael M. Burke
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Liana Macpherson
- MRC Clinical Trials Unit at University College London, London, England, United Kingdom
| | - Moses Kumwenda
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Hussein H. Twabi
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Helse-Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Matteo Quartagno
- MRC Clinical Trials Unit at University College London, London, England, United Kingdom
| | - Peter MacPherson
- Public Health Research Group, Malawi-Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
- School of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Hanif Esmail
- MRC Clinical Trials Unit at University College London, London, England, United Kingdom
- WHO Collaborating Centre on Tuberculosis Research and Innovation, Institute for Global Health, University College London, London, United Kingdom
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Mshamu S, Meta J, Sanga C, Day N, Mukaka M, Adhikari B, Deen J, Knudsen J, Pell C, von Seidlein L. Care seeking for childhood illnesses in rural Mtwara, south-east Tanzania: a mixed methods study. Trans R Soc Trop Med Hyg 2024; 118:465-473. [PMID: 38700078 PMCID: PMC11224983 DOI: 10.1093/trstmh/trae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/12/2023] [Accepted: 03/22/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Care seeking was assessed in preparation for a study of the health impact of novel design houses in rural Mtwara, Tanzania. METHODS A total of 578 residents of 60 villages participated in this mixed-methods study from April to August 2020. Among them, 550 participated in a healthcare-seeking survey, 17 in in-depth interviews and 28 in key informant interviews. RESULTS The decision to seek care was based on symptom severity (95.4% [370]). Caregivers first visited non-allopathic healthcare providers or were treated at home, which led to delays in seeking care at healthcare facilities. More than one-third (36.0% [140]) of respondents took >12 h seeking care at healthcare facilities. The majority (73.0% [282]) visited healthcare facilities, whereas around one-fifth (21.0% [80]) sought care at drug stores. Treatment costs deterred respondents from visiting healthcare facilities (61.4% [338]). Only 10 (3.6%) of the households surveyed reported that they were covered by health insurance. CONCLUSIONS Quality of care, related to institutional factors, impacts timely care seeking for childhood illnesses in Mtwara, Tanzania. Ensuring accessibility of facilities is therefore not sufficient.
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Affiliation(s)
- Salum Mshamu
- CSK Research Solutions, Mtwara, Tanzania
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Nicholas Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mavuto Mukaka
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Bipin Adhikari
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Jakob Knudsen
- Royal Danish Academy – Architecture, Design, Conservation, Copenhagen, Denmark
| | - Christopher Pell
- Amsterdam University Medical Center, University of Amsterdam, Department of Global Health, Amsterdam, the Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Lorenz von Seidlein
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Pokharel S, Adhikari B, Johnson T, Cheah PY. Interventions to address antimicrobial resistance: an ethical analysis of key tensions and how they apply in low- income and middle-income countries. BMJ Glob Health 2024; 9:e012874. [PMID: 38569658 PMCID: PMC11002359 DOI: 10.1136/bmjgh-2023-012874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 01/14/2024] [Indexed: 04/05/2024] Open
Abstract
Antimicrobial resistance (AMR) is a global health and one health problem. Efforts to mitigate the problem of AMR are challenging to implement due to unresolved ethical tensions. We present an in-depth ethical analysis of tensions that might hinder efforts to address AMR. First, there is a tension between access and excess in the current population: addressing lack of access requires facilitating use of antimicrobials for some populations, while addressing excessive use for other populations. Second, there is a tension between personal interests and a wider, shared interest in curbing AMR. These personal interests can be viewed from the perspective of individuals seeking care and healthcare providers whose livelihoods depend on using or selling antimicrobials and who profit from the sales and use of antimicrobials. Third, there is a tension between the interests of current populations and the interests of future generations. Last, there is a tension between addressing immediate health threats such as pandemics, and AMR as a 'silent', chronic threat. For each of these tensions, we apply 'descriptive ethics' methods that draw from existing evidence and our experiences living and working in low-income and middle-income countries to highlight how these ethical tensions apply in such settings.
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Affiliation(s)
- Sunil Pokharel
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Bipin Adhikari
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University Phayathai Campus, Bangkok, Thailand
| | - Tess Johnson
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Phaik Yeong Cheah
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University Phayathai Campus, Bangkok, Thailand
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Lemma Tirore L, Ersido T, Beyene Handiso T, Shiferaw Areba A. Non-adherence to anti-tuberculosis treatment and associated factors among TB patients in public health facilities of Hossana town, Southern Ethiopia, 2022. Front Med (Lausanne) 2024; 11:1360351. [PMID: 38515986 PMCID: PMC10954787 DOI: 10.3389/fmed.2024.1360351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/23/2024] [Indexed: 03/23/2024] Open
Abstract
Background Non-adherence to anti-tuberculosis treatment is one of the crucial challenges to improving TB treatment outcomes and reducing healthcare costs. The prevalence of non-adherence to anti-tuberculosis treatment is not well documented in the study context. Therefore, this study was aimed at estimating the prevalence of non-adherence to anti-tuberculosis treatment and associated factors among TB patients attending TB clinics in Hosanna town, Southern Ethiopia, in 2022. Methods An institution-based cross-sectional study was conducted from April to May 2022. A systematic random sampling technique was employed to select a sample of 233 study subjects from all four public health facilities. According to the order of arrival, every second person was interviewed. Data were collected using a structured questionnaire that was created using several works of literature. A multivariable binary logistic regression analysis was used to identify factors associated with non-adherence to anti-TB drugs. The adjusted odds ratio (AOR) with a 95% confidence interval (CI) was estimated. Results The study included 233 tuberculosis (TB) patients with a response rate of 100%. The prevalence of non-adherence was 18% (95% CI: 15.39, 21.82). Being in the continuation phase (AOR = 3.09, 95% CI: 1.16, 8.23), not attending formal education (AOR = 2.47, 95% CI: 1.12, 5.42), not disclosing TB status to their family (AOR = 2.36, 95% CI: 0.11, 5.04) and having poor TB knowledge (AOR = 3.09, 95% CI: 1.48, 6.48) were significantly associated with non-adherence to TB treatment. Conclusion Among TB patients, there was a significant prevalence of non-adherence to anti-TB medications. Interventions that target patients with low education status, are in the continuation phase, and do not disclose their TB status to their families are required to improve TB treatment adherence. In addition, improving health education is important to enhance TB knowledge, which has an impact on TB treatment adherence. The need for good drug adherence should be emphasized while counseling TB patients.
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McNabb KC, Bergman AJ, Patil A, Lowensen K, Mthimkhulu N, Budhathoki C, Perrin N, Farley JE. Travel distance to rifampicin-resistant tuberculosis treatment and its impact on loss to follow-up: the importance of continued RR-TB treatment decentralization in South Africa. BMC Public Health 2024; 24:578. [PMID: 38389038 PMCID: PMC10885440 DOI: 10.1186/s12889-024-17924-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Understanding why patients experience loss to follow-up (LTFU) is essential for TB control. This analysis examines the impact of travel distance to RR-TB treatment on LTFU, which has yet to be analyzed within South Africa. METHODS We retrospectively analyzed 1436 patients treated for RR-TB at ten South African public hospitals. We linked patients to their residential ward using data reported to NHLS and maps available from the Municipal Demarcation Board. Travel distance was calculated from each patient's ward centroid to their RR-TB treatment site using the georoute command in Stata. The relationship between LTFU and travel distance was modeled using multivariable logistic regression. RESULTS Among 1436 participants, 75.6% successfully completed treatment and 24.4% were LTFU. The median travel distance was 40.96 km (IQR: 17.12, 63.49). A travel distance > 60 km increased odds of LTFU by 91% (p = 0.001) when adjusting for HIV status, age, sex, education level, employment status, residential locale, treatment regimen, and treatment site. CONCLUSION People living in KwaZulu-Natal and Eastern Cape travel long distances to receive RR-TB care, placing them at increased risk for LTFU. Policies that bring RR-TB treatment closer to patients, such as further decentralization to PHCs, are necessary to improve RR-TB outcomes.
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Affiliation(s)
- Katherine C McNabb
- Johns Hopkins University School of Nursing, 525 N Wolfe St, Baltimore, MD, 21205, USA.
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Baltimore, MD, USA.
| | - Alanna J Bergman
- Johns Hopkins University School of Nursing, 525 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Baltimore, MD, USA
| | - Amita Patil
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Baltimore, MD, USA
| | - Kelly Lowensen
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Baltimore, MD, USA
| | - Nomusa Mthimkhulu
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Port Shepstone, Republic of South Africa
| | - Chakra Budhathoki
- Johns Hopkins University School of Nursing, 525 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Baltimore, MD, USA
| | - Nancy Perrin
- Johns Hopkins University School of Nursing, 525 N Wolfe St, Baltimore, MD, 21205, USA
| | - Jason E Farley
- Johns Hopkins University School of Nursing, 525 N Wolfe St, Baltimore, MD, 21205, USA
- Johns Hopkins Center for Infectious Disease and Nursing Innovation, Baltimore, MD, USA
- Johns Hopkins TB Research Advancement Center, Baltimore, MD, USA
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Dormechele W, Bonsu EO, Boadi C, Adams MO, Hlormenu BA, Addo SK, Bossman BB, Addo IY. Determinants of intention to conceal tuberculosis status among family members: an analysis of seven Sub-Saharan African countries. BMC Infect Dis 2024; 24:175. [PMID: 38331730 PMCID: PMC10854020 DOI: 10.1186/s12879-024-09064-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 01/27/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a significant public health burden in Sub-Saharan Africa (SSA), accounting for about 25% of global TB cases. In several communities, TB diagnosis, treatment, and control have become a critical challenge, largely due to the intention to conceal TB status among family members. It is therefore crucial to understand the factors associated with the intentions to conceal TB status among family members in SSA. METHODS This quantitative study utilised data from the most recent Demographic and Health Surveys (DHS). The objective was to examine the factors associated with the intention to conceal the TB status of family members. The sample consisted of 58,849 individuals aged 10 years or older from seven SSA countries. Binary logistic regression was employed to assess the associations between TB status concealment and various socio-demographic and economic variables. RESULTS The overall prevalence of TB status concealment intentions for the seven countries was 28.0% (95% CI: 27.6-28.4). Malawi and Eswatini accounted for the highest (47.3%) and lowest (3.0%) prevalence of TB concealment intentions respectively. TB status concealment intentions decreased with increasing age (p < 0.001). Living in rural areas was associated with lower odds of intending to conceal the TB of family members compared to living in urban areas (aOR = 0.92; p = 0.008). Higher education levels were associated with lower odds of TB status concealment intentions (aOR = 0.50; p < 0.001) compared to lower education levels. As participants wealth index increased, the odds of TB status concealment intentions decreased (aOR = 0.83; p < 0.001). Country of residence also showed significant associations with individuals in Ghana (aOR = 4.51; p < 0.001), Lesotho (aOR = 2.08; p < 0.001), Malawi (aOR = 4.10; p < 0.001), Namibia (aOR = 4.40; p < 0.001), and Sao-Tome and Principe (aOR = 5.56; p < 0.001) showing higher odds of TB status concealment intentions compared to Eswatini. CONCLUSIONS The findings conclude that several social determinants of health, including age, urbanicity, education, and wealth contribute to TB status concealment intentions for family members. Considering these factors is important for designing targeted interventions to improve TB control in the sample. In light of the unavailability of cultural variables in the dataset, future research can leverage qualitative approaches to conduct a more comprehensive exploration of the cultural factors linked to TB status concealment intentions in the population.
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Affiliation(s)
| | - Emmanuel Osei Bonsu
- Department of Epidemiology and Biostatistics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Caleb Boadi
- Department of Operations and Management Information Systems, University of Ghana, Accra, Ghana
| | | | | | | | | | - Isaac Yeboah Addo
- Centre for Social Research in Health, University of New South Wales, Sydney, NSW, Australia.
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Wang X, Fu Q, Zhou M, Li Y. How Integrated Digital Tools Can Improve Tuberculosis Medication Adherence: A Longitudinal Study in China. Telemed J E Health 2024; 30:490-498. [PMID: 37498525 DOI: 10.1089/tmj.2023.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
Background: Poor medication adherence remains one of the major problems in the treatment of tuberculosis (TB) patients, while digital technologies have been proven effective to improve the treatment results. However, reports on the effectiveness of comprehensive practice integrating different intervention methods and technologies are limited. The aim of this study is to evaluate the effectiveness of an integrated digital adherence intervention for TB patients. Methods: We developed a digital adherence intervention platform integrating instant WeChat message, electronic medication monitors (EMMs), and manual reminders. The primary goal of the platform was to improve the accessibility of digital adherence technologies, and thus improve treatment adherence. TB patients were newly diagnosed at 10 TB-designated hospitals and came from 220 communities, from January to June 2022. The basic characteristics and treatment adherence of TB patients in WeChat, EMM, and conventional groups were compared, and the influencing factors of high medication adherence were analyzed by logistic regression. Results: A total of 2,498 TB patients were enrolled in the study, 14.5% were managed by digital technologies, 9.5% by WeChat, and 5.0% by EMM, respectively. After intervention, the median medication rate of TB patients was significantly higher in the WeChat group (95.3%) and EMM group (95.7%) compared with that of the conventional group (83.8%). On the contrary, the median number of missed medications among patients of the conventional group (nine times) was significantly higher than that in the WeChat (three times) group and EMM (three times) group. The proportion of high adherence (adherence medication rate ≥90%) among TB patients was 64.7%, 64.5%, and 43.2% in WeChat, EMM, and conventional group, respectively. Conclusions: The application of the integrated digital adherence intervention platform could significantly improve medication adherence among TB patients. The accessibility of digital adherence technologies could be improved by integrating complementary technologies in practice.
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Affiliation(s)
- Xiaojun Wang
- Wuhan Institute for Tuberculosis Control, Wuhan Pulmonary Hospital, Wuhan, China
| | - Qian Fu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meilan Zhou
- Wuhan Institute for Tuberculosis Control, Wuhan Pulmonary Hospital, Wuhan, China
| | - Yuehua Li
- Wuhan Institute for Tuberculosis Control, Wuhan Pulmonary Hospital, Wuhan, China
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9
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Sejie GA, Mahomed OH. Potential facilitators and inhibitors to the implementation and sustainability of the community-based tuberculosis care interventions. A case study from Moshupa, Botswana. PLoS One 2023; 18:e0290010. [PMID: 37561753 PMCID: PMC10414663 DOI: 10.1371/journal.pone.0290010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 07/31/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Eliminating Tuberculosis is one of the targets of Sustainable Development Goal Three. Decentralizing TB care beyond health facilities by leveraging community involvement is crucial for safeguarding effective tuberculosis care. In this study, we explored potential facilitators and inhibitors of the implementation and sustainability of community-based interventions for the prevention and treatment of TB in the Moshupa district, Botswana. METHODS This study adopted a qualitative approach using a collective case design. An interpretive paradigm based on relativist ontology and subjectivist epistemology along with abductive research logic was used. The study enrolled treatment supporters of tuberculosis patients diagnosed with drug-susceptible tuberculosis between January 2019 and December 2019 in Moshupa Village for semi-structured interviews, Health care professionals for in-depth interviews, and e community leaders for focus group discussions. Clinic-based observations in Mma-Seetsele clinic were also conducted to corroborate the participants' views. The data collected was analyzed using the NVivo version 12 software package, and statements of the participants were presented as quotes to substantiate the issues discussed. RESULTS This study highlighted effective partnerships between health services and external stakeholders, community empowerment, and the availability of policies and standard operating procedures as facilitators of community TB implementation and sustainability. However, Insufficient funding, low service provider training, policies not embracing age and educational eligibility for treatment supporters, shortage of equipment, medicines, and supplies, inadequate transport availability and incentives to meet clients' basic needs, paper-based systems, inadequate supervision, incomplete data reporting, and low service quality affected the Community TB program efficacy and sustainability in Moshupa. We also found that there was low service provider motivation and retention and that clients had low trust in treatment supporters. CONCLUSION The findings of this study imply that the operational effectiveness of the community TB care approach to disease elimination is compromised; therefore, initiatives addressing the key components, including the availability of resources, governance arrangements and supportive systems for community health workers, are required for successful community TB implementation and sustainability.
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Affiliation(s)
- Gabalape Arnold Sejie
- Discipline of Public Health Medicine, University of KwaZulu, Natal, Durban, South Africa
- Department of Health Promotion and Education, Boitekanelo College, Gaborone, Botswana
| | - Ozayr H. Mahomed
- Discipline of Public Health Medicine, University of KwaZulu, Natal, Durban, South Africa
- Dasman Diabetes Institute, Kuwait City, Kuwait
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Fenta MD, Ogundijo OA, Warsame AAA, Belay AG. Facilitators and barriers to tuberculosis active case findings in low- and middle-income countries: a systematic review of qualitative research. BMC Infect Dis 2023; 23:515. [PMID: 37550614 PMCID: PMC10405492 DOI: 10.1186/s12879-023-08502-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 07/31/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) is an ancient infection and a major public health problem in many low- and middle-income countries (LMICs). Active case finding (ACF) programs have been established to effectively reduce TB in endemic global communities. However, there is little information about the evidence-based benefits of active case finding at both the individual and community levels. Accurately identifying the facilitators and barriers to TB-ACF provides information that can be used in planning and design as the world aims to end the global TB epidemic by 2035. Therefore, this study aimed to identify the facilitators and barriers to tuberculosis ACF in LMICs. METHODS A systematic search was performed using recognized databases such as PubMed, Google Scholar, SCOPUS, HINARI, and other reference databases. Relevant studies that assessed or reported the ACF of TB conducted in LMICs were included in this study. The Joanna Briggs Institute's (JBI) Critical Appraisal Tool was used to assess the quality of the selected studies. The Statement of Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) was used to strengthen the protocol for this systematic review. The Confidence of Evidence Review Quality (CERQual) approach was also used to assess the reliability of the review findings. RESULTS From 228 search results, a total of 23 studies were included in the final review. Tuberculosis ACF results were generated under two main themes: barriers and facilitators in LMICs, and two sub-themes of the barriers (healthcare-related and non-healthcare-related barriers). Finally, barriers to active TB case finding were found to be related to (1) the healthcare workers' experience, knowledge, and skills in detecting TB-ACF, (2) distance and time; (3) availability and workload of ACF healthcare workers; (4) barriers related to a lack of resources such as diagnostic equipment, reagents, and consumables at TB-ACF; (5) the stigma associated with TB-ACF detection; (6) the lack of training of existing and new healthcare professionals to detect TB-ACF; (7) communication strategies and language limitations associated with TB ACF; and (8) poor or no community awareness of tuberculosis. Stigma was the most patient-related obstacle to detecting active TB cases in LMICs. CONCLUSION This review found that surveillance, monitoring, health worker training, integration into health systems, and long-term funding of health facilities were key to the sustainability of ACF in LMICs. Understanding the elimination of the identified barriers is critical to ensuring a maximum tuberculosis control strategy through ACF.
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Affiliation(s)
- Melkie Dagnaw Fenta
- Department of Clinical Veterinary Medicine, University of Gondar, Gondar, Ethiopia.
| | - Oluwaseun Adeolu Ogundijo
- Department of Veterinary Public Health and Preventive Medicine, University of Ibadan, Ibadan, Nigeria
| | - Ahmed Abi Abdi Warsame
- Department of Animal Production and Marketing, Faculty of Agriculture and Environment Science, Gulu University, Gulu, Uganda
| | - Abebaw Getachew Belay
- Department of Veterinary Public Health and Epidemiology, University of Gondar, Gondar, Ethiopia
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Bengey D, Thapa A, Dixit K, Dhital R, Rai B, Paudel P, Paudel R, Majhi G, Aryal TP, Sah MK, Pandit RN, Mishra G, Khanal MN, Kibuchi E, Caws M, de Siqueira-Filha NT. Comparing cross-sectional and longitudinal approaches to tuberculosis patient cost surveys using Nepalese data. Health Policy Plan 2023; 38:830-839. [PMID: 37300553 PMCID: PMC10394499 DOI: 10.1093/heapol/czad037] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/12/2023] Open
Abstract
The World Health Organization has supported the development of national tuberculosis (TB) patient cost surveys to quantify the socio-economic impact of TB in high-burden countries. However, methodological differences in the study design (e.g. cross-sectional vs longitudinal) can generate different estimates making the design and impact evaluation of socio-economic protection strategies difficult. The objective of the study was to compare the socio-economic impacts of TB estimated by applying cross-sectional or longitudinal data collections in Nepal. We analysed the data from a longitudinal costing survey (patients interviewed at three time points) conducted between April 2018 and October 2019. We calculated both mean and median costs from patients interviewed during the intensive (cross-sectional 1) and continuation (cross-sectional 2) phases of treatment. We then compared costs, the prevalence of catastrophic costs and the socio-economic impact of TB generated by each approach. There were significant differences in the costs and social impacts calculated by each approach. The median total cost (intensive plus continuation phases) was significantly higher for the longitudinal compared with cross-sectional 2 (US$119.42 vs 91.63, P < 0.001). The prevalence of food insecurity, social exclusion and patients feeling poorer or much poorer were all significantly higher by applying a longitudinal approach. In conclusion, the longitudinal design captured important aspects of costs and socio-economic impacts, which were missed by applying a cross-sectional approach. If a cross-sectional approach is applied due to resource constraints, our data suggest that the start of the continuation phase is the optimal timing for a single interview. Further research to optimize methodologies to report patient-incurred expenditure during TB diagnosis and treatment is needed.
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Affiliation(s)
- Daisy Bengey
- Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
| | - Anchal Thapa
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Kritika Dixit
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
- Department of Global Public Health, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Raghu Dhital
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Bhola Rai
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Puskar Paudel
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Rajan Paudel
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Govind Majhi
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | | | - Manoj Kumar Sah
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | | | - Gokul Mishra
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
| | - Mukti Nath Khanal
- Planning Monitoring Evaluation & Research Section, National Tuberculosis Control Center, Thimi, Bhaktapur, Nepal
| | - Eliud Kibuchi
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, 90 Byres Road, Glasgow G12 8TB, United Kingdom
| | - Maxine Caws
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Ward No. 2, Nepal
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12
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Sarwar G, Khan SM, Irfan SD, Khan MNM, Reza MM, Rana AKMM, Banu RS, Ahmed S, Banu S, Khan SI. Community based peer-led TB screening intervention: an innovative approach to increase TB knowledge, presumptive case identification, and referral among sexual minority people in urban Bangladesh. BMC Health Serv Res 2023; 23:810. [PMID: 37507688 PMCID: PMC10386687 DOI: 10.1186/s12913-023-09737-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 06/22/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION One of the contributors to tuberculosis (TB) burden among vulnerable populations, such as sexual minority people, is the delay in case finding and notification. Given their socially excluded, hard-to-reach nature, community-led approaches need to be introduced to facilitate their screening of TB symptoms and their subsequent referral to TB healthcare providers. This article aimed to explore the existing challenges surrounding TB screening and referral, and the implementation facilitators and barriers of the proposed community-based TB screening model for sexual minority people in Dhaka, Bangladesh. METHODS This study followed the quasi-experimental design using mixed methods (i.e., qualitative and quantitative) approach. The study participants who were also a part of the community-led TB screening model included sexual minority people enrolled in HIV prevention interventions. In addition to quantitative inquiry, in-depth interviews were conducted on sexual minority people, focus group discussions were also conducted on them and HIV prevention service providers, and key-informant interviews were conducted on service providers, programmatic experts and TB researchers. Data were analyzed using content, contextual and thematic approaches. RESULTS The 'Six Steps in Quality Intervention Development' framework was used to guide the development of the community-based TB screening model. In Step 1 (identifying the problem), findings revealed low rates of TB screening among sexual minority people enrolled in the HIV prevention intervention. In Step 2 (identifying contextual factors for change), various individual, and programmatic factors were identified, which included low knowledge, low-risk perception, prioritization of HIV services over TB, and stigma and discrimination towards these populations. In Step 3 (deciding change mechanism), community-based screening approaches were applied, thus leading to Step 4 (delivery of change mechanism) which designed a community-based approach leveraging the peer educators of the HIV intervention. Step 5 (testing intervention) identified some barriers and ways forward for refining the intervention, such as home-based screening and use of social media. Step 6 (collecting evidence of effectiveness) revealed that the main strength was its ability to engage peer educators. CONCLUSION This study indicates that a community-based peer-led TB screening approach could enhance TB screening, presumptive TB case finding and referral among these populations. Therefore, this study recommends that this approach should be incorporated to complement the existing TB program.
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Affiliation(s)
- Golam Sarwar
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani Mohakhali, Dhaka, 1212, Bangladesh
| | - Shaan Muberra Khan
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani Mohakhali, Dhaka, 1212, Bangladesh
| | - Samira Dishti Irfan
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani Mohakhali, Dhaka, 1212, Bangladesh
| | - Mohammad Niaz Morshed Khan
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani Mohakhali, Dhaka, 1212, Bangladesh
| | - Md Masud Reza
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani Mohakhali, Dhaka, 1212, Bangladesh
| | - A K M Masud Rana
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani Mohakhali, Dhaka, 1212, Bangladesh
| | - Rupali Sisir Banu
- National Tuberculosis Control Programme (NTP), Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare (MOH&FW), Dhaka, Bangladesh
| | - Shahriar Ahmed
- Programme for Emerging Infections, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sayera Banu
- Programme for Emerging Infections, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sharful Islam Khan
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani Mohakhali, Dhaka, 1212, Bangladesh.
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Zaildo T, Santino TA, Chaves G, da Silva BAK, Alchieri JC, Patino CM, Leite S, Luz KG, Guerra RO, da Penha THS, da Silva GR, Jácome AC, Monteiro KS, de Mendonça KMPP. Barriers to and facilitators of populational adherence to prevention and control measures of COVID-19 and other respiratory infectious diseases: a qualitative evidence synthesis. Eur Respir Rev 2023; 32:220238. [PMID: 37343960 DOI: 10.1183/16000617.0238-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 04/03/2023] [Indexed: 06/23/2023] Open
Abstract
AIMS To summarise the evidence on barriers to and facilitators of population adherence to prevention and control measures for coronavirus disease 2019 (COVID-19) and other respiratory infectious diseases. METHODS A qualitative synthesis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis and the Cochrane Effective Practice and Organization of Care: Qualitative Evidence Synthesis. We performed an electronic search on MEDLINE, Embase and PsycINFO from their inception to March 2023. RESULTS We included 71 studies regarding COVID-19, pneumonia, tuberculosis, influenza, pertussis and H1N1, representing 5966 participants. The measures reported were vaccinations, physical distancing, stay-at-home policy, quarantine, self-isolation, facemasks, hand hygiene, contact investigation, lockdown, infection prevention and control guidelines, and treatment. Tuberculosis-related measures were access to care, diagnosis and treatment completion. Analysis of the included studies yielded 37 barriers and 23 facilitators. CONCLUSIONS This review suggests that financial and social support, assertive communication, trust in political authorities and greater regulation of social media enhance adherence to prevention and control measures for COVID-19 and infectious respiratory diseases. Designing and implementing effective educational public health interventions targeting the findings of barriers and facilitators highlighted in this review are key to reducing the impact of infectious respiratory diseases at the population level.
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Affiliation(s)
- Tácito Zaildo
- Department of Physical Therapy, Graduate Program in Physical Therapy, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Thayla Amorim Santino
- Department of Physical Therapy, State University of Paraiba, Campina Grande, PB, Brazil
| | | | | | - João Carlos Alchieri
- Department of Psychology, Graduate Program in Science, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Cecilia M Patino
- Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Sarah Leite
- Department of Physical Therapy, Graduate Program in Physical Therapy, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Kleber Giovanni Luz
- Department of Infectious Diseases, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Ricardo Oliveira Guerra
- Department of Physical Therapy, Graduate Program in Physical Therapy, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Tito Hugo Soares da Penha
- Department of Physical Therapy, Graduate Program in Physical Therapy, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Gabriel Rodrigues da Silva
- Department of Physical Therapy, Graduate Program in Physical Therapy, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Ada Cristina Jácome
- Public Health Department of the State of Rio Grande do Norte, Natal, RN, Brazil
| | - Karolinne Souza Monteiro
- Faculty of Health Sciences of Trairi, Federal University of Rio Grande do Norte, Natal, RN, Brazil
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Sodhi R, Penkunas MJ, Pal A. Free drug provision for tuberculosis increases patient follow-ups and successful treatment outcomes in the Indian private sector: a quasi experimental study using propensity score matching. BMC Infect Dis 2023; 23:421. [PMID: 37344775 DOI: 10.1186/s12879-023-08396-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/11/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND The private sector is an important yet underregulated component of the TB treatment infrastructure in India. The Joint Effort for Elimination of Tuberculosis (Project JEET) aims to link private sector TB care with the constellation of social support mechanisms available through the Indian National TB Elimination Programme (NTEP), including the provision of free fixed-dose combination (FDCs) drugs to patients. This quasi-experimental study analysed routinely collected data to determine the impact of free drugs on patient follow-ups and treatment outcomes. METHODS We used data for private sector patients enrolled with Project JEET who were diagnosed with pulmonary and extrapulmonary TB between 1 and 2019 and 31 March 2020, and completed treatment by 31 December 2021. Propensity score matching was used to create a dataset to compare the number of follow-ups and proportion of successful treatment outcomes for patients on free drugs to a control group who paid out-of-pocket. 11,621 matched pairs were included in the analysis. Logistic regression and ordinary least squares regression models were used to estimate the impact of free drugs on number of follow-ups and treatment success, where latter is defined as treatment completion or cure. RESULTS After controlling for potential confounders, patients on free drugs received on average 2.522 (95% C.I.: 2.325 to 2.719) additional follow-ups compared to patients who paid out of pocket. This equates to a 25% mean and 32% median increase in follow-ups for patients availing free drugs. For treatment success, patients receiving free drugs had 45% higher odds of a successful treatment (Odds Ratio: 1.452, 95% C.I.: 1.288 to 1.637). CONCLUSIONS Patients receiving free drugs were found to follow up with their treatment coordinator more frequently, in part likely to enable drug refilling, compared to patients who were paying out of pocket. These additional contacts would have offered opportunities to address concerns regarding side effects, provide additional treatment information, and connect with social support services, all of which subsequently contributed to patients' continual engagement with their treatment. This potentially represents the unmeasured effect of free drugs on continual social support, which translates into a higher odds of treatment success for patients.
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Affiliation(s)
- Ridhima Sodhi
- Clinton Health Access Initiative, Inc., New Delhi, India.
| | | | - Arnab Pal
- Clinton Health Access Initiative, Inc., New Delhi, India
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15
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Baral S, Yadav RK, Yadav DK, Marahatta SB, Baral Y, Khadka KB, Thakur SK, Paudel S, Sharma P, Pandey S, Shrestha K, Shah NP, Basaula L, Nagila A, Mahato RK, Ranabhat CL. Feasibility of implementing public-private mix approach for tuberculosis case management in Pokhara Metropolitan City of western Nepal: a qualitative study. Front Public Health 2023; 11:1132090. [PMID: 37293622 PMCID: PMC10244665 DOI: 10.3389/fpubh.2023.1132090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/12/2023] [Indexed: 06/10/2023] Open
Abstract
Background The Public-Private Mix (PPM) approach is a strategic initiative that involves engaging all private and public health care providers in the fight against tuberculosis using international health care standards. For tuberculosis control in Nepal, the PPM approach could be a milestone. This study aimed to explore the barriers to a public-private mix approach in the management of tuberculosis cases in Nepal. Methods We conducted key informant interviews with 20 participants, 14 of whom were from private clinics, polyclinics, and hospitals where the PPM approach was used, two from government hospitals, and four from policymakers. All data were audio-recorded, transcribed, and translated into English. The transcripts of the interviews were manually organized, and themes were generated and categorized into 1. TB case detection, 2. patient-related barriers, and 3. health-system-related barriers. Results A total of 20 respondents participated in the study. Barriers to PPM were identified into following three themes: (1) Obstacles related to TB case detection, (2) Obstacles related to patients, and (3) Obstacles related to health-care system. PPM implementation was challenged by following sub-themes that included staff turnover, low private sector participation in workshops, a lack of trainings, poor recording and reporting, insufficient joint monitoring and supervision, poor financial benefit, lack of coordination and collaboration, and non-supportive TB-related policies and strategies. Conclusion Government stakeholders can significantly benefit by applying a proactive role working with the private in monitoring and supervision. The joint efforts with private sector can then enable all stakeholders to follow the government policy, practice and protocols in case finding, holding and other preventive approaches. Future research are essential in exploring how PPM could be optimized.
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Affiliation(s)
- Sushila Baral
- Center for Mental Health and Counselling Nepal (CMC Nepal), Kathmandu, Nepal
- Department of Public Health, Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
| | | | - Dipendra Kumar Yadav
- Department of Public Health, School of Health and Allied Sciences, Pokhara University, Pokhara, Nepal
| | - Sujan Babu Marahatta
- Department of Public Health, Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
| | - Yadunath Baral
- Department of Orthopedics, Pokhara Academy of Health Sciences, Pokhara, Nepal
| | - Khim Bahadur Khadka
- Health Directorate, Minstry of Health and Population (MoHP), Gandaki Province, Pokhara, Nepal
| | | | - Srijana Paudel
- Department of Medicine, Pokhara Academy of Health Sciences, Pokhara, Nepal
| | - Prabin Sharma
- Provincial Health Training Center, Gandaki Province, Pokhara, Nepal
| | - Sony Pandey
- Department of Public Health, Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
| | - Kusum Shrestha
- Provincial Government, Health Office, Damauli, Tanahun, Nepal
| | | | - Laxman Basaula
- Health Directorate, Minstry of Health and Population (MoHP), Gandaki Province, Pokhara, Nepal
| | - Amar Nagila
- Department of Medical Microbiology, School of Health and Allied Sciences, Pokhara University, Pokhara, Nepal
| | | | - Chhabi Lal Ranabhat
- Department of Public Health, Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
- Global Center for Research and Development, Kathmandu, Nepal
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Shringarpure K, Gurumurthy M, Sagili KD, Taylor M, Garner P, Tonsing J, Rao R, Sachdeva KS. Patient adherence to tuberculosis treatment in the Indian subcontinent: systematic review and meta-synthesis of qualitative research. BMJ Open 2023; 13:e063926. [PMID: 37142319 PMCID: PMC10163483 DOI: 10.1136/bmjopen-2022-063926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVES How well patients adhere to their tuberculosis (TB) treatment influences their recovery and development of drug resistance, but influences on adherence are multiple and often competing. We synthesised qualitative studies from our setting in the Indian subcontinent to understand the dimensions and dynamics involved to help inform service provision. DESIGN Qualitative synthesis comprising inductive coding, thematic analysis and forming a conceptual framework. DATA SOURCES Medline (OVID), Embase (OVID), CINAHL (EBSCOHost), PsycINFO (EBSCOHost), Web of Science Core Collection, Cochrane Library and Epistemonikos were databases searched on 26 March 2020 for studies published since 1 January 2000. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included reports in English from the Indian subcontinent that used qualitative or mixed-methodology designs and reported findings around adherence to TB treatment. Full texts meeting eligibility were sampled based on 'thickness' (the richness of the qualitative data reported). DATA EXTRACTION AND SYNTHESIS Two reviewers used standardised methods to screen abstracts and code. Included studies were assessed for reliability and quality using a standard tool. Qualitative synthesis was performed by inductive coding, thematic analysis and developing conceptual framework. RESULTS Of 1729 abstracts screened from initial search, 59 were shortlisted for full-text review. Twenty-four studies that qualified as 'thick' were included in the synthesis. Studies were set in India (12), Pakistan (6), Nepal (3), Bangladesh (1) or in two or more of these countries (2). Of the 24 studies, all but one included people who were taking TB treatment (1 study included only healthcare providers), and 17 included healthcare workers, community members or both.We identified three themes: (1) personal influences on the people with TB include interconnections between their social role in the family unit, their own priorities in day-to-day living and their experience to date with the disease; (2) adherence is profoundly influenced by how individual healthcare providers interact with patients on treatment and address their needs; (3) adherence is influenced across communities by structural, social, economic and cultural factors related to treatment. CONCLUSION Staff in TB programmes require an understanding of the various competing influences on individuals undergoing treatment. Programmes need to have more flexible and people-centred approaches to service provision in order to achieve adherence, and thus improve treatment outcomes. PROSPERO REGISTRATION NUMBER CRD42020171409.
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Affiliation(s)
- Kalpita Shringarpure
- Department of Community Medicine, Medical College Baroda, Baroda, Gujarat, India
| | - Meera Gurumurthy
- Research Division, Vital Strategies, Singapore
- TB Department, International Union Against Tuberculosis and Lung Disease (The Union), South East Asia Office, New Delhi, India
| | - Karuna D Sagili
- TB Department, International Union Against Tuberculosis and Lung Disease (The Union), South East Asia Office, New Delhi, India
| | - Melissa Taylor
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Paul Garner
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jamie Tonsing
- TB Department, International Union Against Tuberculosis and Lung Disease (The Union), South East Asia Office, New Delhi, India
- The Global Fund to Fight AIDS Tuberculosis and Malaria, Grand-Saconnex, Geneva, Switzerland
| | - Raghuram Rao
- National Tuberculosis Elimination Programme (NTEP), Central TB Division, India Ministry of Health and Family Welfare, New Delhi, India
| | - Kuldeep Singh Sachdeva
- TB Department, International Union Against Tuberculosis and Lung Disease (The Union), South East Asia Office, New Delhi, India
- National Tuberculosis Elimination Programme (NTEP), Central TB Division, India Ministry of Health and Family Welfare, New Delhi, India
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Shabadi N, Prashanth Kumar NK, Prakash B, Kulkarni P, Narayana Murthy MR. Stakeholders' perspective on the daily regimen of tuberculosis treatment- A qualitative approach. Indian J Tuberc 2023; 70:226-231. [PMID: 37100580 DOI: 10.1016/j.ijtb.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/15/2022] [Accepted: 05/20/2022] [Indexed: 04/28/2023]
Abstract
INTRODUCTION In the context of changing over from an intermittent treatment regimen to a daily regimen, it becomes crucial to understand the impact of a daily regimen on the treatment process and outcome. It enables health professionals to strengthen strategies, to enhance the quality of treatment as well as the quality of life of TB patients. The perspective of each stakeholder involved in the process is important in assessing the impact of the daily regimen. OBJECTIVES To understand patients' and providers' perspectives on the daily regimen of Tuberculosis treatment. METHODOLOGY A qualitative study was conducted between March 2020 to June 2020, including in-depth interviews with TB patients on treatment and DOT providers, and Key Informant Interview(KII) with TB Health Visitors(TBHV) and family members of TB patients. A thematic-network analysis approach was utilized to get the results. RESULTS Two sub-themes emerged: (i) Acceptance of the daily regimen of treatment; (ii) operational difficulties of the daily regimen. No injections in the regimen, fewer side effects of drugs as dose depends on weight band, family members can be treatment supporter, awareness about disease and treatment, the drugs are as same as private drugs available, adherence has improved, monthly DBT were found to some of the enablers in the study. The Barriers found in the study were traveling daily to get drugs, loss of daily wages, accompanying patients daily, tracing private patients, pyridoxine is not given free in this regimen, increased workload for treatment providers, etc. CONCLUSION: The study points out that acceptance of the patient to the daily regimen is better as they have lesser side effects. The operational difficulties in the implementation of the daily regimen can be addressed by providing family members as treatment supporters.
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Affiliation(s)
- Nayanabai Shabadi
- Department of Community Medicine, JSS Medical College, JSS Academy of Higher Education and Research (JSSAHER), Mysuru, Karnataka, India.
| | - N K Prashanth Kumar
- School of Public Health, JSS Academy of Higher Education and Research (JSSAHER), Mysuru, Karnataka, India
| | - B Prakash
- Department of Community Medicine, Panimalar Medical College Hospital & Research Institute, Varadharajapuram, Poonamalle, Chennai, Tamilnadu, India
| | - Praveen Kulkarni
- Department of Community Medicine, JSS Medical College, JSS Academy of Higher Education and Research (JSSAHER), Mysuru, Karnataka, India
| | - M R Narayana Murthy
- Department of Community Medicine, JSS Medical College, JSS Academy of Higher Education and Research (JSSAHER), Mysuru, Karnataka, India
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An Y, Teo AKJ, Huot CY, Tieng S, Khun KE, Pheng SH, Leng C, Deng S, Song N, Nonaka D, Yi S. Barriers to childhood tuberculosis case detection and management in Cambodia: the perspectives of healthcare providers and caregivers. BMC Infect Dis 2023; 23:80. [PMID: 36750767 PMCID: PMC9903406 DOI: 10.1186/s12879-023-08044-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/30/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Diagnosis and treatment of tuberculosis (TB) in children remain challenging, particularly in resource-limited settings. Healthcare providers and caregivers are critical in improving childhood TB screening and treatment. This study aimed to determine the barriers to childhood TB detection and management from the perspectives of healthcare providers and caregivers in Cambodia. METHOD We conducted this qualitative study between November and December 2020. Data collection included in-depth interviews with 16 healthcare providers purposively selected from four operational districts and 28 caregivers of children with TB and children in close contact with bacteriologically confirmed pulmonary TB residing in the catchment areas of the selected health centers. Data were analyzed using thematic analyses. RESULTS Mean ages of healthcare providers and caregivers were 40.2 years (standard deviation [SD] 11.9) and 47.9 years (SD 14.6), respectively. Male was predominant among healthcare providers (93.8%). Three-fourths of caregivers were female, and 28.6% were grandparents. Inadequate TB staff, limited knowledge on childhood TB, poor collaboration among healthcare providers in different units on TB screening and management, limited quality of TB diagnostic tools, and interruption of supplies of childhood TB medicines due to maldistribution from higher levels to health facilities were the key barriers to childhood TB case detection and management. Caregivers reported transportation costs to and from health facilities, out-of-pocket expenditure, time-consuming, and no clear explanation from healthcare providers as barriers to childhood TB care-seeking. Aging caregivers with poor physical conditions, lack of collaboration from caregivers, ignorance of healthcare provider's advice, and parent movement were also identified as barriers to childhood TB case detection and management. CONCLUSIONS The national TB program should further invest in staff development for TB, scale-up appropriate TB diagnostic tools and ensure its functionalities, such as rapid molecular diagnostic systems and X-ray machines, and strengthen childhood TB drug management at all levels. These may include drug forecasting, precise drug distribution and monitoring mechanism, and increasing community awareness about TB to increase community engagement.
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Affiliation(s)
- Yom An
- Sustaining Technical and Analytical Resources (STAR), The Public Health Institute (PHI), Phnom Penh, Cambodia. .,School of Health Sciences, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan. .,School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia.
| | - Alvin Kuo Jing Teo
- grid.4280.e0000 0001 2180 6431Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore ,grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, University of Sydney, Sydney, NSW Australia
| | - Chan Yuda Huot
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - Sivanna Tieng
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - Kim Eam Khun
- grid.436334.5School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia ,National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - Sok Heng Pheng
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - Chhenglay Leng
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | | | - Ngak Song
- United States Agency for International Development, Phnom Penh, Cambodia
| | - Daisuke Nonaka
- grid.267625.20000 0001 0685 5104School of Health Sciences, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Siyan Yi
- grid.436334.5School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia ,grid.4280.e0000 0001 2180 6431Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore ,grid.513124.00000 0005 0265 4996KHANA Center for Population Health Research, Phnom Penh, Cambodia ,grid.265117.60000 0004 0623 6962Center for Global Health Research, Touro University California, Vallejo, CA USA
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Jops P, Cowan J, Kupul M, Trumb RN, Graham SM, Bauri M, Nindil H, Bell S, Keam T, Majumdar S, Pomat W, Marais B, Marks GB, Kaldor J, Vallely A, Kelly-Hanku A. Beyond patient delay, navigating structural health system barriers to timely care and treatment in a high burden TB setting in Papua New Guinea. Glob Public Health 2023; 18:2184482. [PMID: 36883701 DOI: 10.1080/17441692.2023.2184482] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Tuberculosis (TB) is a major public health issue in Papua New Guinea, with incidence rates particularly high in the South Fly District of Western Province. We present three case studies, along with additional vignettes, that were derived from interviews and focus groups carried out between July 2019 and July 2020 of people living in rural areas of the remote South Fly District depicting their challenges accessing timely TB diagnosis and care; most services within the district are only offered offshore on Daru Island. The findings detail that rather than 'patient delay' attributed to poor health seeking behaviours and inadequate knowledge of TB symptoms, many people were actively trying to navigate structural barriers hindering access to and utilisation of limited local TB services. The findings highlight a fragile and fragmented health system, a lack of attention given to primary health services, and undue financial burdens placed on people living in rural and remote areas associated with costly transportation to access functioning health services. We conclude that a person-centred and effective decentralised model of TB care as outlined in health policies is imperative for equitable access to essential health care services in Papua New Guinea.
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Affiliation(s)
- Paula Jops
- Kirby Institute, UNSW Sydney, Sydney, Australia
| | - John Cowan
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Martha Kupul
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Richard Nake Trumb
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Stephen M Graham
- Burnet Institute, Melbourne, Australia.,Centre for International Child Health, University of Melbourne, Melbourne, Australia
| | - Mathias Bauri
- Western Provincial Health Authority, Daru, Papua New Guinea
| | - Herolyn Nindil
- National TB Program, National Department of Health, Port Moresby, Papua New Guinea
| | - Stephen Bell
- Centre for Social Research in Health, UNSW Sydney, Sydney, Australia.,School of Public Health, The University of Queensland, Brisbane, Australia
| | - Tess Keam
- Burnet Institute, Melbourne, Australia
| | - Suman Majumdar
- Burnet Institute, Melbourne, Australia.,Centre for International Child Health, University of Melbourne, Melbourne, Australia
| | - William Pomat
- Kirby Institute, UNSW Sydney, Sydney, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Ben Marais
- Sydney Institute for Infectious Diseases (Sydney ID), University of Sydney, Sydney, Australia
| | - Guy B Marks
- Woolcock Institute of Medical Research, Sydney, Australia.,Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - John Kaldor
- Kirby Institute, UNSW Sydney, Sydney, Australia
| | - Andrew Vallely
- Kirby Institute, UNSW Sydney, Sydney, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Angela Kelly-Hanku
- Kirby Institute, UNSW Sydney, Sydney, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
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20
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Andom AT, Gilbert HN, Ndayizigiye M, Mukherjee JS, Lively CT, Nthunya J, Marole TA, Ratsiu M, Smith Fawzi MC, Yuen CM. Understanding barriers to tuberculosis diagnosis and treatment completion in a low-resource setting: A mixed-methods study in the Kingdom of Lesotho. PLoS One 2023; 18:e0285774. [PMID: 37167298 PMCID: PMC10174523 DOI: 10.1371/journal.pone.0285774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 04/28/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Lesotho is one of the 30 countries with the highest tuberculosis incidence rates in the world, estimated at 650 per 100,000 population. Tuberculosis case detection is extremely low, particularly with the rapid spread of COVID-19, dropping from an estimated 51% in 2020 to 33% in 2021. The aim of this study is to understand the barriers to tuberculosis diagnosis and treatment completion. METHODS We used a convergent mixed methods study design. We collected data on the number of clients reporting symptoms upon tuberculosis screening, their sputum test results, the number of clients diagnosed, and the number of clients who started treatment from one district hospital and one health center in Berea district, Lesotho. We conducted in-depth interviews and focus group discussions with 53 health workers and patients. We used a content analysis approach to analyze qualitative data and integrated quantitative and qualitative findings in a joint display. FINDINGS During March-August, 2019, 218 clients at the hospital and 292 clients at the health center reported tuberculosis symptoms. The full diagnostic testing process was completed for 66% of clients at the hospital and 68% at the health center. Among clients who initiated tuberculosis treatment, 68% (61/90) at the hospital and 74% (32/43) at the health center completed treatment. The main barriers to testing and treatment completion were challenges at sample collection, lack of decentralized diagnostic services, and socioeconomic factors such as food insecurity and high patient movement to search for jobs. CONCLUSIONS Tuberculosis diagnosis could be improved through the effective decentralization of laboratory services at the health facility level, and treatment completion could be improved by providing food and other forms of social support to patients.
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Affiliation(s)
- Afom T Andom
- Partners In Health-Lesotho, Maseru, Lesotho
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Hannah N Gilbert
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | | | - Joia S Mukherjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States of America
- Partners In Health, Boston, MA, United States of America
| | - Christina Thompson Lively
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | | | | | | | - Mary C Smith Fawzi
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Courtney M Yuen
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States of America
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21
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Mahato P, Adhikari B, Marahatta SB, Bhusal S, Kunwar K, Yadav RK, Baral S, Adhikari A, van Teijlingen E. Perceptions around COVID-19 and vaccine hesitancy: A qualitative study in Kaski district, Western Nepal. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000564. [PMID: 36962942 PMCID: PMC10022296 DOI: 10.1371/journal.pgph.0000564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/28/2022] [Indexed: 02/19/2023]
Abstract
Burgeoning morbidity and mortality due to COVID-19 pandemic including the peaks in outbreaks due to different variants have attracted global attention. Although the development and rolling out of vaccines have been impressive, low- and middle-income countries suffer from a double burden: (1) lack of adequate vaccines; and (2) low vaccine uptake (vaccine hesitancy). The main objective of this study was to explore perceptions around COVID-19 and vaccine hesitancy among urban and rural population in Western Nepal. A qualitative study was conducted in six urban wards of Pokhara municipality and four rural municipalities in Kaski district of Nepal. A semi-structured interview guide was used to interview participants who were selected purposively to explore the perceived burden of COVID-19 pandemic, roles, and contributions of vaccine. Nineteen interviews were conducted by telephone following a government recommendation to avoid face-to-face meetings. Audio-recorded interviews were thematically analysed after transcription and translation into English. COVID-19 is a major (public) health concern and affects people at an individual, societal and national level. People dreaded its health hazards and consequences and seemed to be compliant with public health measures such as maintaining social distance, wearing masks and maintaining hygiene. Vaccine was considered to be a major intervention to fight the pandemic, nonetheless, the rationale and benefits of vaccines were blemished by the perceived lack of the vaccine's effectiveness, duration of protection, and its potential side-events. Expedited development of vaccine was embraced with suspicion that vaccine may have incurred compromise in quality. Science and rationale behind vaccine were smeared by misinformation and clearly counteracting the misinformation were deemed critical. Providing information about vaccines through government entities (who are trusted) and respected individuals may engender trust and uptake of vaccine. Fighting off misinformation of COVID-19 is critical to curb the course of pandemic. Increased attention towards monitoring and investing in legitimacy of information and offering information through trusted sources can help improve the vaccine coverage.
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Affiliation(s)
- Preeti Mahato
- Department of Health Studies, School of Life Sciences and the Environment, Royal Holloway University of London, Egham, United Kingdom
- Centre for Midwifery, Maternal & Perinatal Health, Bournemouth University, Bournemouth, United Kingdom
| | - Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, United Kingdom
| | | | - Susagya Bhusal
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
| | - Kshitij Kunwar
- Central Department of Public Health, Tribhuwan University, Kirtipur, Nepal
| | | | - Sushila Baral
- Provincial Health Training Centre, Gandaki Province, Nepal
| | - Anisha Adhikari
- School of Health and Allied Sciences, Pokhara University, Pokhara, Nepal
| | - Edwin van Teijlingen
- Centre for Midwifery, Maternal & Perinatal Health, Bournemouth University, Bournemouth, United Kingdom
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22
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Kwabla M, Klett-Tammen CJ, Castell S. Barriers and motivation for presumptive tuberculosis case referral: qualitative analysis among operators of community medicine outlets in Ghana. BMC Health Serv Res 2022; 22:980. [PMID: 35915498 PMCID: PMC9341095 DOI: 10.1186/s12913-022-08321-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Community medicine outlets (CMOs) are the first point of call for individuals presenting with cough in Ghana. Although operators of CMOs comprising pharmacists and over-the-counter (OTC) medicine sellers largely support the public–private mix strategy which seeks to engage pharmacies in tuberculosis (TB) case detection, a significant proportion is not involved in TB referral services. The study explores the barriers to and motivation for presumptive TB case referral among CMO operators. Methods We used open- and close-ended questions nested in a telephone survey which assessed factors associated with presumptive TB case referral among CMO operators (n = 465). We interviewed participants using computer assisted telephone interviews and analysed the qualitative data using adjusted Mayring’s structured qualitative content analysis. Results Based on participants’ own experiences, non-referral was attributed to negative attitudes of presumed cases (48.2%) and inability to meet the financial demands of referred presumed cases (26.3%). Regarding their perception of barriers to TB referral for their professional colleagues, an assumed lack of TB training (44.5%) and an assumed negative attitude of operators (43.6%) were mentioned. From close-ended questions, most chosen barriers to referral were: the assumption of not having seen a presumptive TB case yet (31.8%), lack of TB training (22.2%) and no monetary motivation for operators (10.5%). Most operators (81.6%) view TB referral services as their social responsibility and feel self-motivated to refer cases in order to control the spread of TB in their communities. Of 152 further comments extracted as recommendations to improve referral, 101 (66.4%) of respondents would only refer with the availability of support systems in the form of TB training and making TB diagnostic testing more accessible. Conclusion Operators of CMOs are predominantly self-motivated to refer presumptive TB cases. Barriers to referral might be mitigated by providing more training to operators and specific financial support such as reimbursement of travel costs to presumptive cases.
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23
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Bain LE, Akondeng C, Njamnshi WY, Mandi HE, Amu H, Njamnshi AK. Community engagement in research in sub-Saharan Africa: current practices, barriers, facilitators, ethical considerations and the role of gender - a systematic review. Pan Afr Med J 2022; 43:152. [PMID: 36785694 PMCID: PMC9922083 DOI: 10.11604/pamj.2022.43.152.36861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 10/20/2022] [Indexed: 02/15/2023] Open
Abstract
Introduction meaningful community engagement is increasingly being considered the major determinant of successful research, innovation and intervention uptake. Even though there is available literature recommending community engagement in health research, there are still knowledge gaps in how communities might be best engaged in Sub-Saharan Africa. We, therefore, synthesized the existing literature on the current practices, barriers and facilitators, ethical considerations, and gender mainstreaming in the engagement of communities in research in sub-Saharan Africa. Methods this synthesis was developed following the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA). A combination of keywords and medical subject headings was used to search MEDLINE, EMBASE, Global Health Library through OVID SP, the Cochrane Library, PsychINFO, CINAHL, WHO Afro Library, WHO Global Index Medicus and the National Institute for Health Research, for all literature published between 1 January 2000 to 31 July 2021. Results thirty articles met our inclusion criteria. The key reported facilitators of effective community engagement in research included appropriate community entry and engagement of stakeholders. Barriers to effective community engagement in research included the availability of prohibitive cultural, historical and religious practices; geographical/spatial limitations, difficulties in planning and executing community engagement activities and communication barriers. Awareness creation and sensitization on the research through drama, social media, documentaries, and community durbars are some of the existing practices adopted in engaging communities in research. Gender mainstreaming was not considered appropriately in the engagement of communities in research, as only a few studies made provisions for gender considerations, and most of the time, interchanging gender for sex. Respect for autonomy, privacy and informed consent were the main ethical issues reported. Conclusion gender mainstreaming and ethical standards were reported as important, but not explored in depth. Gender as a social construct needs to be carefully integrated in the entire research cycle. Clear ethical concerns within a research project have to be co-discussed by the research team, community members and potential research participants.
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Affiliation(s)
- Luchuo Engelbert Bain
- Triangle Research Foundation (TRIFT), Limbe, Cameroon,,Department of Psychology, Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa,,Global South Health Services and Research (GSHS), Amsterdam, The Netherlands,,Corresponding author: Luchuo Engelbert Bain, Triangle Research Foundation (TRIFT), Limbe, Cameroon.
| | - Claudine Akondeng
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon,,Cameroon National Association of Family Welfare (CAMNAFAW), Yaoundé, Cameroun
| | - Wepnyu Yembe Njamnshi
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon,,Education and Learning for All (ELFA) Cameroon, Yaoundé, Cameroon,,Division of Operational Research in Health, DROS, Ministry of Public Health, Yaoundé, Cameroon
| | - Henshaw Eyambe Mandi
- Triangle Research Foundation (TRIFT), Limbe, Cameroon,,Coalition for Epidemic Preparedness Innovations, Oslo, Norway
| | - Hubert Amu
- Department of Population and Behavioral Sciences, Fred N. Binka School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Alfred Kongnyu Njamnshi
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon,,Education and Learning for All (ELFA) Cameroon, Yaoundé, Cameroon,,Faculty of Medicine and Biomedical Sciences (FMBS), The University of Yaoundé I, Yaoundé, Cameroon
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24
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Tornu E, Quarcoopome L. Correlates of quality of life among persons living with tuberculosis: A cross-sectional study. PLoS One 2022; 17:e0277192. [PMID: 36331938 PMCID: PMC9635747 DOI: 10.1371/journal.pone.0277192] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction The correlates of quality of life originating from the demographic characteristics, comorbidities and sources of social support among persons living with tuberculosis remain underreported. The aim of this study was to examine the correlates of quality of life among persons living with tuberculosis within Greater Accra, Ghana. Methods A cross-sectional survey design was used to assess the correlates of quality of life among 250 randomly sampled persons living with tuberculosis. Quality of life was assessed with the Quality of Life Brief Version (WHOQOL-BREF) questionnaire and correlates were derived using Spearman rho correlations. Chi-square analyses assessed associations among respondent characteristics. Results All four quality of life domains (physical, psychological, social relationship and environmental) of persons living with tuberculosis were positively correlated. Furthermore, receiving social support from family or friends correlated positively with respondents’ quality of life. Human Immunodeficiency Virus (HIV) infection and receiving social support mainly from work colleagues or religious institutions correlated negatively with respondents’ quality of life domains. Other correlates of quality of life included age, pleuritis with pleural effusion, number of dependants and distance to tuberculosis treatment centres. Social support from family and friends corresponded with better quality of life among persons living with tuberculosis. Conclusion The quality of life domains of persons living with tuberculosis are interrelated and can be enhanced by social support. Healthcare providers should involve the significant others of persons living with tuberculosis, human immunodeficiency virus and pleuritis with pleural effusion in their care to promote patients’ quality of life.
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Affiliation(s)
- Eric Tornu
- Department of Adult Health, School of Nursing and Midwifery, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Louisa Quarcoopome
- Department of Internal Medicine and Therapeutics, Korle-Bu Teaching Hospital, Korle-Bu, Accra, Ghana
- * E-mail:
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25
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Muller N, Ranjaharinony F, Etrahagnane M, Frühauf A, Razafindranaivo T, Ramasimanana H, Emmrich JV. Crossing the Last Mile of TB Care in Rural Southern Madagascar: A Multistakeholder Initiative. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2200101. [PMID: 36316148 PMCID: PMC9622284 DOI: 10.9745/ghsp-d-22-00101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 10/04/2022] [Indexed: 06/16/2023]
Abstract
Despite a free TB care policy, access to TB care in rural Madagascar is limited due to a markedly underfunded health care system. The World Health Organization estimated the yearly TB incidence in Madagascar at 238 cases per 100,000 people in 2020; only half of the patients with TB are being notified and treated. We describe the development, implementation, and lessons learned of an intervention to improve TB care services in a remote, rural district in southern Madagascar. We involved national, regional, and local stakeholders in assessing the multifaceted challenges in a remote, rural area and codesigning activities to address them. The overarching principles of the intervention were to (1) promote national TB guidelines, (2) build on best practices, and (3) prioritize low-cost activities to enable scale-up. An in-depth assessment of challenges in accessing and delivering TB care resulted in the following prioritization of activities: (1) fostering community engagement, (2) decentralizing service provision, (3) improving quality of care, (4) providing nutritional support, and (5) ensuring staff support and supervision. The intervention was launched in September 2019 and is ongoing as of October 2022. During mobile TB clinics conducted between September 2019 and December 2020, 4,982 presumptive patients were screened and 1,706 (34.2%) have been diagnosed with TB. Based on 2010-2020 official TB notification data, we calculated trend-adjusted additional TB notifications during the intervention, resulting in a 2.6-fold increase in cases in 2019-2020. The intervention district's TB notification rate increased from 178 cases per 100,000 people in 2018 to 424 cases per 100,000 people in 2020. Involving stakeholders from all levels of care was perceived as a key to success. The unexpected increase in the number of patients with TB in the intervention district overburdened the current paper-based TB notification system and emphasized the need for expanded diagnostics and social support services.
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Affiliation(s)
- Nadine Muller
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.
- Charité Global Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Anna Frühauf
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité Global Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Julius Valentin Emmrich
- Charité Global Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
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26
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Akwongo B, Katuura E, Nsubuga AM, Tugume P, Andama M, Anywar G, Namaganda M, Asimwe S, Kakudidi EK. Ethnobotanical study of medicinal plants utilized in the management of candidiasis in Northern Uganda. Trop Med Health 2022; 50:78. [PMID: 36242066 PMCID: PMC9569084 DOI: 10.1186/s41182-022-00471-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background The emergence of resistant Candida species to antifungal drugs has led to resurgence in herbal usage globally. However, little is known about anti-candida plants. This study explored ethnomedicinal plants as treatment option for candidiasis in Pader, Northern Uganda.
Methods A cross-sectional survey of potential anti-candida plants was conducted using questionnaires, focus group discussions and field observations in March 2022. Sixty-three respondents were selected by snowball technique. The frequencies of respondents/responses were analyzed, associations of respondents’ socio-demographics with indigenous knowledge of herbal usage established by Chi-square (χ2) test using SPSS 27. Informant Consensus Factor was computed to establish level of agreement on herbal usage, and thematic analysis done for focus group discussions. Results Candidiasis is still common and troublesome in Pader. All herbalist had equal chances of receiving and treating candidiasis patients irrespective of herbalist’s gender, age, education level, occupation, marital status and religion (p > 0.05). About 39.7% of herbalists received candidiasis patients weekly (p < 0.01). All herbalists had knowledge on candidiasis. Death (56.8%) and discomfort (36.8%) were the major health risks of oropharyngeal candidiasis (OPC) and vulvovaginal candidiasis (VVC), respectively. A total of 32 potential anti-candida plant species in 18 families were identified. Families of Fabaceae (9 species) and Asteraceae (5 species) had most plant species. Trees (50.0%) and herbs (43.8%) were the dominant life forms. The commonest plants by frequency of mention were: Momordica foetida (26), Sansevieria dawei (20), Khaya anthotheca (15), Piliostigma thonningii (10), Clerodendrum umbellatum (7), Hallea rubrostipulata (5) and unidentified plant, ‘Agaba/daa layata’ in Acholi dialect (5). Plant parts mainly used were roots (56.3%) and stem barks (15.6%) harvested majorly by cutting (46.9%) and uprooting (12.5%). Most respondents (females, 95%) preferred herbal to western medication (p < 0.01) due to its perceived effectiveness. There was high consensus among herbalists on herbal remedies for OPC and VVC (FIC = 0.9). Conclusions Pader communities have diverse indigenous knowledge on candidiasis and prefer herbal medicines to orthodox treatment for candidiasis. However, the herbalists use unsustainable harvesting techniques like uprooting whole plants and cutting main roots. Hence, the need to document such indigenous knowledge before being lost for community usage and scientific validation.
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Affiliation(s)
- Betty Akwongo
- Department of Plant Science, Microbiology and Biotechnology, School of Biosciences, College of Natural Sciences, Makerere University, P. O. Box 7062, Kampala, Uganda. .,Department of Biology, Faculty of Science, Muni University, P.O. Box 725, Arua, Uganda.
| | - Esther Katuura
- Department of Plant Science, Microbiology and Biotechnology, School of Biosciences, College of Natural Sciences, Makerere University, P. O. Box 7062, Kampala, Uganda
| | - Anthony M Nsubuga
- Department of Plant Science, Microbiology and Biotechnology, School of Biosciences, College of Natural Sciences, Makerere University, P. O. Box 7062, Kampala, Uganda
| | - Patience Tugume
- Department of Plant Science, Microbiology and Biotechnology, School of Biosciences, College of Natural Sciences, Makerere University, P. O. Box 7062, Kampala, Uganda
| | - Morgan Andama
- Department of Biology, Faculty of Science, Muni University, P.O. Box 725, Arua, Uganda
| | - Godwin Anywar
- Department of Plant Science, Microbiology and Biotechnology, School of Biosciences, College of Natural Sciences, Makerere University, P. O. Box 7062, Kampala, Uganda
| | - Mary Namaganda
- Department of Plant Science, Microbiology and Biotechnology, School of Biosciences, College of Natural Sciences, Makerere University, P. O. Box 7062, Kampala, Uganda
| | - Savina Asimwe
- Department of Plant Science, Microbiology and Biotechnology, School of Biosciences, College of Natural Sciences, Makerere University, P. O. Box 7062, Kampala, Uganda
| | - Esezah Kyomugisha Kakudidi
- Department of Plant Science, Microbiology and Biotechnology, School of Biosciences, College of Natural Sciences, Makerere University, P. O. Box 7062, Kampala, Uganda
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Adhikari B, Tripura R, Dysoley L, Callery JJ, Peto TJ, Heng C, Vanda T, Simvieng O, Cassidy-Seyoum S, Ley B, Thriemer K, Dondorp AM, von Seidlein L. Glucose 6 Phosphate Dehydrogenase (G6PD) quantitation using biosensors at the point of first contact: a mixed method study in Cambodia. Malar J 2022; 21:282. [PMID: 36195916 PMCID: PMC9531219 DOI: 10.1186/s12936-022-04300-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quantitative measurement of Glucose-6-Phosphate Dehydrogenase (G6PD) enzyme activity is critical to decide on appropriate treatment and provision of radical cure regimens for vivax malaria. Biosensors are point-of-care semi-quantitative analysers that measure G6PD enzyme activity. The main objective of this study was to evaluate the operational aspects of biosensor deployment in the hands of village malaria workers (VMWs) in Cambodia over a year. METHODS Following initial orientation and training at Kravanh Referral Hospital, each VMW (n = 28) and laboratory technician (n = 5) was provided a biosensor (STANDARD SD Biosensor, Republic of Korea) with supplies for routine use. Over the next 12 months VMWs convened every month for refresher training, to collect supplies, and to recalibrate and test their biosensors. A quantitative self-administered questionnaire was used to assess the skills necessary to use the biosensor after the initial training. Subsequently, VMWs were visited at their location of work for field observation and evaluation using an observer-administered questionnaire. All quantitative questionnaire-based data were analysed descriptively. Semi-structured interviews (SSIs) were conducted among all participants to explore their experience and practicalities of using the biosensor in the field. SSIs were transcribed and translated into English and underwent thematic analysis. RESULTS A total of 33 participants completed the training and subsequently used the biosensor in the community. Quantitative assessments demonstrated progressive improvement in skills using the biosensor. VMWs expressed confidence and enthusiasm to use biosensors in their routine work. Providing G6PD testing at the point of first contact avoids a multitude of barriers patients have to overcome when travelling to health centres for G6PD testing and radical cure. Deploying biosensors in routine work of VMWs was also considered an opportunity to expand and strengthen the role of VMWs as health care providers in the community. VMWs reported practical concerns related to the use of biosensor such as difficulty in using two pipettes, difficulty in extracting the code chip from the machine, and the narrow base of buffer tube. CONCLUSIONS VMWs considered the biosensor a practical and beneficial tool in their routine work. Providing VMWs with biosensors can be considered when followed by appropriate training and regular supervision. Providing community management of vivax malaria at the point of first contact could be key for elimination.
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Affiliation(s)
- Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Rupam Tripura
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Lek Dysoley
- C.N.M National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - James J Callery
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Thomas J Peto
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Chhoeun Heng
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Thy Vanda
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ou Simvieng
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Sarah Cassidy-Seyoum
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Benedikt Ley
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Kamala Thriemer
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Lorenz von Seidlein
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Community pharmacists-led interventions in tuberculosis care: A systematic review. Res Social Adm Pharm 2022; 19:5-15. [PMID: 36096865 DOI: 10.1016/j.sapharm.2022.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 08/10/2022] [Accepted: 09/01/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND A multidisciplinary approach is required to tackle the tuberculosis (TB) epidemic, which is one of the most pressing public health concerns worldwide. However, community pharmacists are underutilized in TB programs. OBJECTIVE To identify community pharmacists-led interventions in TB management with their corresponding impacts in TB case detection and treatment outcomes. METHODS A systematic search was performed in six electronic databases and health organization websites, from database inception to August 2, 2022. Studies which described TB screening, referral and/or treatment monitoring by community pharmacists with their corresponding outcomes were screened and reviewed independently by two reviewers. The studies were checked for the risk of bias using Cochrane risk of bias tools. All data of included studies were analysed qualitatively and presented narratively. RESULTS The search yielded 8,121 studies and five reports for initial screening. Sixteen studies and two case study reports were included in this review. Community pharmacists were involved throughout the TB care cascade, contributing their services in TB screening, referrals and in directly observed treatment-short course (DOTS) program. These interventions showed improvements in the effective control and prevention of further spread of TB, which improves individual, community and population level outcomes. CONCLUSIONS The inclusion of community pharmacists into TB program can improve the continuity of care, bridging the gaps in TB case detection and treatment monitoring. Adequate training and support are essential, to further empower the role of community pharmacists in TB control and prevention, in building a TB-free world.
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Yield and Coverage of Active Case Finding Interventions for Tuberculosis Control:A Systematic Review and Meta-analysis. Tuberc Res Treat 2022; 2022:9947068. [PMID: 35837369 PMCID: PMC9274229 DOI: 10.1155/2022/9947068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/28/2022] [Accepted: 06/09/2022] [Indexed: 11/17/2022] Open
Abstract
Background Active case finding (ACF) for tuberculosis (TB) is a key strategy to reduce diagnostic delays, expedite treatment, and prevent transmission. Objective Our objective was to identify the populations, settings, screening and diagnostic approaches that optimize coverage (proportion of those targeted who were screened) and yield (proportion of those screened who had active TB) in ACF programs. Methods We performed a comprehensive search to identify studies published from 1980-2016 that reported the coverage and yield of different ACF approaches. For each outcome, we conducted meta-analyses of single proportions to produce estimates across studies, followed by meta-regression to identify predictors. Findings. Of 3,972 publications identified, 224 met criteria after full-text review. Most individuals who were targeted successfully completed screening, for a pooled coverage estimate of 93.5%. The pooled yield of active TB across studies was 3.2%. Settings with the highest yield were internally-displaced persons camps (15.6%) and healthcare facilities (6.9%). When compared to symptom screening as the reference standard, studies that screened individuals regardless of symptoms using microscopy, culture, or GeneXpert®MTB/RIF (Xpert) had 3.7% higher case yield. In particular, microbiological screening (usually microscopy) as the initial test, followed by culture or Xpert for diagnosis had 3.6% higher yield than symptom screening followed by microscopy for diagnosis. In a model adjusted for use of Xpert testing, approaches targeting persons living with HIV (PLWH) had a 4.9% higher yield than those targeting the general population. In all models, studies targeting children had higher yield (4.8%-5.7%) than those targeting adults. Conclusion ACF activities can be implemented successfully in various populations and settings. Screening yield was highest in internally-displaced person and healthcare settings, and among PLWH and children. In high-prevalence settings, ACF approaches that screen individuals with laboratory tests regardless of symptoms have higher yield than approaches focused on symptomatic individuals.
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Jenkins HE, Ayuk S, Puma D, Brooks MB, Millones AK, Jimenez J, Lecca L, Galea JT, Becerra M, Keshavjee S, Yuen CM. Geographic accessibility to health facilities predicts uptake of community-based tuberculosis screening in an urban setting. Int J Infect Dis 2022; 120:125-131. [PMID: 35470023 PMCID: PMC9176313 DOI: 10.1016/j.ijid.2022.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 01/13/2023] Open
Abstract
Objectives: Annually, more than 30% of individuals with tuberculosis (TB) remain undiagnosed. We aimed to assess whether geographic accessibility measures can identify neighborhoods that would benefit from TB screening services targeted toward closing the diagnosis gap. Methods: We used data from a community-based mobile TB screening program in Carabayllo district, Lima, Peru. We constructed four accessibility measures from the geographic center of neighborhoods to health facilities. We used logistic regression to assess the association between these measures and screening uptake in one’s residential neighborhood versus elsewhere, with quasi-information criterion values to assess the association. Results: We analyzed the screening locations for 25,000 Carabayllo residents from 49 neighborhoods. Pedestrian walk time was preferable to Euclidean distance or vehicular time in our models. For each additional 12 minutes walking time between the neighborhood and the health facility, the odds of residents using TB screening units located in their neighborhoods increased by 50% (95% CI: 26%–78%). Females had 9% (95% CI: 3%–16%) increased odds versus males of using a screening unit in their own neighborhood. Conclusion: Placing mobile TB screening units in neighborhoods with longer pedestrian time to access health facilities could benefit individuals who face more acute access barriers to health care.
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Affiliation(s)
| | - Sally Ayuk
- University of Texas at Arlington, Arlington, Texas, USA
| | | | | | | | | | - Leonid Lecca
- Socios en Salud Sucursal Peru, Lima, Peru; Harvard Medical School, Boston, MA, USA
| | - Jerome T Galea
- School of Social Work, University of South Florida, Tampa, FL, USA; College of Public Health, University of South Florida, Tampa, FL, USA
| | | | - Salmaan Keshavjee
- Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
| | - Courtney M Yuen
- Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA.
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Rayamajhi P, Nepal G, Ojha R, Rajbhandari R, Gajurel BP, Karn R. Evaluating cognitive outcomes in adult patients with acute encephalitis syndrome: a prospective study from a tertiary care center in Nepal. ENCEPHALITIS 2022; 2:36-44. [PMID: 37469649 PMCID: PMC10295914 DOI: 10.47936/encephalitis.2021.00157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 10/22/2021] [Accepted: 11/08/2021] [Indexed: 07/21/2023] Open
Abstract
Purpose Although cognitive impairment is a known complication of acute encephalitis syndrome (AES), few studies have evaluated cognitive outcomes in patients with encephalitis. The primary objective of this study was to assess the cognitive profiles of patients diagnosed with AES, which is pivotal for improving rehabilitation strategies and prognostic measures. Methods This study was conducted at the Tribhuvan University Teaching Hospital. Adult patients with AES who met inclusion criteria were enrolled. The Montreal Cognitive Assessment (MoCA) tool was used to assess cognitive function at admission, discharge, and 3-month follow-up. Results Thirty-six patients were enrolled in our study. The mean age of the participants was 43 ± 18 years. Fourteen patients (38.9%) were female, and 22 (61.1%) were male. Tuberculous (TB) meningoencephalitis was present in 14 cases (38.9%), with herpes simplex virus (HSV) encephalitis in 14 (38.9%), bacterial meningoencephalitis in 4 (11.1%), autoimmune encephalitis in 2 (5.6%), and Japanese encephalitis in 2 (5.6%). Patients with bacterial meningoencephalitis had the highest MoCA scores at admission, whereas those with HSV encephalitis had the highest scores at discharge and follow-up. Compared with the scores at admission, the scores at discharge and follow-up increased significantly in patients with TB meningoencephalitis and HSV encephalitis. The MoCA score at discharge was established as a significant predictor of cognitive function at follow-up. Conclusion We found that active treatment can improve the outcomes of AES patients with cognitive impairment. Although infectious etiologies are most common in low-income countries such as Nepal, autoimmune etiologies should not be overlooked.
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Affiliation(s)
- Parash Rayamajhi
- Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Reema Rajbhandari
- Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | | | - Ragesh Karn
- Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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Der JB, Grant AD, Grint D, Narh CT, Bonsu F, Bond V. Barriers to tuberculosis case finding in primary and secondary health facilities in Ghana: perceptions, experiences and practices of healthcare workers. BMC Health Serv Res 2022; 22:368. [PMID: 35305634 PMCID: PMC8934052 DOI: 10.1186/s12913-022-07711-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 02/28/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Ghana's national tuberculosis (TB) prevalence survey conducted in 2013 showed higher than expected TB prevalence indicating that many people with TB were not being identified and treated. Responding to this, we assessed barriers to TB case finding from the perspective, experiences and practices of healthcare workers (HCWs) in rural and urban health facilities in the Volta region, Ghana. METHODS We conducted structured clinic observations and in-depth interviews with 12 HCWs (including five trained in TB case detection) in four rural health facilities and a municipal hospital. Interview transcripts and clinic observation data were manually organised, triangulated and analysed into health system-related and HCW-related barriers. RESULTS The key health system barriers identified included lack of TB diagnostic laboratories in rural health facilities and no standard referral system to the municipal hospital for further assessment and TB testing. In addition, missed opportunities for early diagnosis of TB were driven by suboptimal screening practices of HCWs whose application of the national standard operating procedures (SOP) for TB case detection was inconsistent. Further, infection prevention and control measures in health facilities were not implemented as recommended by the SOP. HCW-related barriers were mainly lack of training on case detection guidelines, fear of infection (exacerbated by lack of appropriate personal protective equipment [PPE]) and lack of motivation among HCWs for TB work. Solutions to these barriers suggested by HCWs included provision of at least one diagnostic facility in each sub-municipality, provision of transport subsidies to enable patients' travel for testing, training of newly-recruited staff on case detection guidelines, and provision of appropriate PPE. CONCLUSION TB case finding was undermined by few diagnostic facilities; inconsistent referral mechanisms; poor implementation, training and quality control of a screening tool and guidelines; and HCWs fearing infection and not being motivated. We recommend training for and quality monitoring of TB diagnosis and treatment with a focus on patient-centred care, an effective sputum transport system, provision of the TB symptom screening tool and consistent referral pathways from peripheral health facilities.
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Affiliation(s)
- Joyce B Der
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK. .,Department of Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana.
| | - Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,School of Laboratory Medicine & Medical Sciences, Africa Health Research Institute, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel Grint
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Clement T Narh
- Department of Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana.,Department of Biostatistics and Informatics, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre, Mainz, Germany
| | - Frank Bonsu
- Department of Disease Control and Prevention, National TB Control Program, Ghana Health Service, Accra, Ghana
| | - Virginia Bond
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Rodríguez-Márquez I, Tello-Hoyos KY, Torres-Pereda P, Guzmán-Salazar BL, Pérez F, Polanco-Pasaje JE. Tuberculosis screening indicators in indigenous population in Colombia: a mixed methods research. CAD SAUDE PUBLICA 2022; 38:e00008621. [PMID: 35293536 DOI: 10.1590/0102-311x00008621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 10/01/2021] [Indexed: 11/22/2022] Open
Abstract
This study aims to evaluate, via a mixed methods study, the implementation of the screening process for pulmonary tuberculosis (PTB) within indigenous population of the Department of Cauca, Colombia, during the 2016-2018 period. Indicators assessing the PTB screening process were elaborated and estimated. Subsequently, an evaluation of the indicators were performed based on a sampling process from health care providers of the municipalities with the highest and lowest PTB incidence and from key agents' perspective. Screening indicators were estimated and thematic analysis was performed based on the interviews conducted with key agents. Finally, a triangulation of quantitative and qualitative findings was performed. From the total population expected to have respiratory symptomatics (n = 16,711), the health care providers were able to identify 42.3% of them. Out of the individuals identified as respiratory symptomatics (n = 7,064), they were able to examine 93.2% (n = 6,585) with at least one acid-fast bacilli smear test. The reported positivity index from acid-fast bacilli smear test was 1.87%. The explanations from key agents revolved around the possibility of an overestimated targeted amount of respiratory symptomatics; insufficient personnel for the search of symptomatic individuals; high costs for the search in areas of difficult access; the need to request permissions from indigenous authorities; culturally ingrained stigma; use of traditional medicine and self-medication; and patient's personal beliefs. This study revealed barriers in the implementation of the screening process for PTB within the indigenous population from the Department of Cauca, mainly in the identifying process of the respiratory symptomatics.
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Affiliation(s)
| | | | | | | | - Freddy Pérez
- Department of Communicable Diseases and Environmental Determinants of Health, Pan American Health Organization, Washington DC, U.S.A
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Adhikari B, Mishra SR, Schwarz R. Transforming Nepal's primary health care delivery system in global health era: addressing historical and current implementation challenges. Global Health 2022; 18:8. [PMID: 35101073 PMCID: PMC8802254 DOI: 10.1186/s12992-022-00798-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/08/2022] [Indexed: 02/07/2023] Open
Abstract
Nepal’s Primary Health Care (PHC) is aligned vertically with disease control programs at the core and a vast network of community health workers at the periphery. Aligning with the globalization of health and the factors affecting global burden of diseases, Nepal echoes the progressive increase in life expectancy, changes in diseases patterns, including the current impact of COVID-19. Nepal’s health system is also accommodating recent federalization, and thus it is critical to explore how the primary health care system is grappling the challenges amidst these changes. In this review, we conducted a narrative synthesis of literature to explore the challenges related to transformation of Nepal’s primary health care delivery system to meet the demands incurred by impact of globalization and recent federalization, covering following database: PubMED, Embase and Google Scholar. Of the 49 articles abstracted for full text review, 37 were included in the analyses. Existing theories were used for constructing the conceptual framework to explain the study findings. The results are divided into four themes. Additional searches were conducted to further support the narrative synthesis: a total of 46 articles were further included in the articulation of main findings. Transforming Nepal’s primary health care system requires a clear focus on following priority areas that include i) Revised efforts towards strengthening of community based primary health care units; ii) Adapting vertical programs to federal governance; iii) Reinforcing the health insurance scheme; and iv) Strengthening an existing network of community health workers and health human resources. This review discusses how these broad goals bear challenges and opportunities.
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Affiliation(s)
- Bipin Adhikari
- Nepal Community Health and Development Centre, Kathmandu, Nepal. .,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | | | - Ryan Schwarz
- Possible, New York, NY, USA.,Brigham and Women's Hospital, Department of Medicine, Division of Global Health Equity, Boston, MA, USA.,Harvard Medical School, Department of Medicine, Boston, MA, USA
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35
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Andom AT, Gilbert HN, Ndayizigiye M, Mukherjee JS, Nthunya J, Marole TA, Smith Fawzi MC, Yuen CM. Understanding reasons for suboptimal tuberculosis screening in a low-resource setting: A mixed-methods study in the Kingdom of Lesotho. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000249. [PMID: 36962295 PMCID: PMC10021370 DOI: 10.1371/journal.pgph.0000249] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/13/2022] [Indexed: 11/19/2022]
Abstract
Lesotho has one of the highest tuberculosis (TB) incidence rates in the world, estimated at 654/100,000 population. However, TB detection remains low, with only 51% of people with TB being diagnosed and treated. The aim of this study was to evaluate implementation of TB screening and identify drivers of suboptimal TB screening in Lesotho. We used a convergent mixed methods study design. We collected data on the number of health facility visits and the number of clients screened for TB during March-August, 2019 from one district hospital and one health center. We conducted interviews and focus group discussions with patients and health workers to elucidate the mechanisms associated with suboptimal screening. Out of an estimated 70,393 visitors to the two health facilities, only 22% of hospital visitors and 48% of health center visitors were asked about TB symptoms. Only 2% of those screened at each facility said that they had TB symptoms, comprising a total of 510 people. Lack of training on tuberculosis screening, overall staff shortages, barriers faced by patients in accessing care, and health care worker mistrust of tuberculosis screening procedures were identified as drivers of suboptimal TB screening. TB screening could be improved by ensuring the availability of well-trained, incentivized, and dedicated screeners at health facilities, and by providing TB screening services in community settings.
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Affiliation(s)
- Afom T Andom
- Partners In Health-Lesotho, Maseru, Lesotho
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Hannah N Gilbert
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | | | - Joia S Mukherjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States of America
- Partners in Health, Boston, MA, United States of America
| | | | | | - Mary C Smith Fawzi
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Courtney M Yuen
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States of America
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Nidoi J, Muttamba W, Walusimbi S, Imoko JF, Lochoro P, Ictho J, Mugenyi L, Sekibira R, Turyahabwe S, Byaruhanga R, Putoto G, Villa S, Raviglione MC, Kirenga B. Impact of socio-economic factors on Tuberculosis treatment outcomes in north-eastern Uganda: a mixed methods study. BMC Public Health 2021; 21:2167. [PMID: 34836521 PMCID: PMC8620143 DOI: 10.1186/s12889-021-12056-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 10/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) is a major public health problem and at 48%, Karamoja in North-Eastern Uganda has the lowest treatment success rate nationally. Addressing the social determinants of TB is crucial to ending TB. This study sought to understand the extent and ways in which socio-economic factors affect TB treatment outcomes in Karamoja. METHODS We conducted a convergent parallel mixed methods study in 10 TB Diagnostic and Treatment Units. The study enrolled former TB patients diagnosed with drug-susceptible TB between April 2018 and March 2019. Unit TB and laboratory registers were reviewed to identify pre-treatment losses to follow-up. Four focus group discussions with former TB patients and 18 key informant interviews with healthcare workers were conducted. Principle component analysis was used to generate wealth quintiles that were compared to treatment outcomes using the proportion test. The association between sociodemographic characteristics and TB treatment outcomes was evaluated using the chi-square test and multiple logistic regression. RESULTS A total of 313 participants were randomly selected from 1184 former TB patients recorded in the unit TB registers. Of these, 264 were contacted in the community and consented to join the study: 57% were male and 156 (59.1%) participants had unsuccessful treatment outcomes. The wealthiest quintile had a 58% reduction in the risk of having an unsuccessful treatment outcome (adj OR = 0.42, 95% CI 0.18-0.99, p = 0.047). People who were employed in the informal sector (adj OR = 4.71, 95% CI 1.18-18.89, p = 0.029) and children under the age of 15 years who were not in school or employed (adj OR = 2.71, 95% CI 1.11-6.62, p = 0.029) had significantly higher odds of unsuccessful treatment outcome. Analysis of the pre-treatment loss to follow-up showed that 17.2% of patients with pulmonary bacteriologically confirmed TB did not initiate treatment with a higher proportion among females (21.7%) than males (13.5%). Inadequate food, belonging to migratory communities, stigma, lack of social protection, drug stock-outs and transport challenges affected TB treatment outcomes. CONCLUSIONS This study confirmed that low socio-economic status is associated with poor TB treatment outcomes emphasizing the need for multi- and cross-sectoral approaches and socio-economic enablers to optimise TB care.
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Affiliation(s)
- Jasper Nidoi
- Makerere University Lung Institute (MLI), Kampala, Uganda.
| | | | | | - Joseph F Imoko
- Makerere University Lung Institute (MLI), Kampala, Uganda
| | | | | | | | | | - Stavia Turyahabwe
- National Tuberculosis and Leprosy Control Program (NTLP), Kampala, Uganda
| | - Raymond Byaruhanga
- National Tuberculosis and Leprosy Control Program (NTLP), Kampala, Uganda
| | | | - Simone Villa
- Centre for Multidisciplinary Research in Health Science, University of Milan, Milan, Italy
| | - Mario C Raviglione
- Centre for Multidisciplinary Research in Health Science, University of Milan, Milan, Italy
| | - Bruce Kirenga
- Makerere University Lung Institute (MLI), Kampala, Uganda
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Toroitich AM, Gebeyehu W, Adan FI, Ogola C, Mohamed HM, Ombeka V, Ogolla C, Oiye S. Elucidation of potential challenges and prospects for regional tuberculosis interventions in East and Horn of Africa: a cross-sectional program assessment. Pan Afr Med J 2021; 39:279. [PMID: 34754356 PMCID: PMC8556745 DOI: 10.11604/pamj.2021.39.279.28028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 08/14/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction cross-border mobility of persons with Tuberculosis (TB) is a global public health concern. We aimed at documenting health systems´ potential bottlenecks and opportunities in pulmonary TB continuum of care in cross-border expanses of East and Horn of Africa. Methods a cross-sectional program assessment with descriptive analysis of TB services, health staff capacities, diagnostic capacities, data management and reporting, and treatment outcomes. Data were extracted from health facility TB registers and semi-structured key informant interviews conducted in selected 26 cross-border sites within the 7 member states of the Intergovernmental Authority on Development (IGAD) region. Results the overall cross-border TB cure rate in the year preceding the study (37%) was way beneath the global target with considerable variations amongst the study countries. The restricted support to the cross-border health facilities was mediated and even exacerbated by expansive distances from the respective capital cities. Restricted geographical access to the facilities by cross-border populations was a longstanding challenge. Substantial staffing gaps, TB service delivery capacity needs and inadequate diagnostics were noticeable. The TB control guidelines were not harmonized between the countries and the inter-country referral systems were either absent or inappreciable, contributing to ineffective cross-border referrals and transfers. The frail linkages between stakeholders were contemptible, but increasing governments´ commitments in tackling infectious diseases were encouraging. Conclusion cross-border TB interventions should drive regional TB policies, strategies and programs that sustain countries´ coordination, harmonization of management guidelines, advocacy for increased human resources support, enhanced capacity building of cross-border TB staff, adequate diagnostics equipping of the cross-border health facilities and seamless transfer and referral of patients traversing boundaries.
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Affiliation(s)
| | | | | | - Christine Ogola
- United States Agency for International Development (USAID) Kenya and East Africa, Health Population and Nutrition Office, Nairobi, Kenya
| | | | - Victor Ombeka
- The Royal Netherlands Tuberculosis Foundation, Tuberculosis Foundation, The Hague, Netherlands
| | - Charles Ogolla
- Intergovernmental Authority on Development, Djibouti, Djibouti
| | - Shadrack Oiye
- Intergovernmental Authority on Development, Djibouti, Djibouti
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Engaging Private Health Care Providers to Identify Individuals with TB in Nepal. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182211762. [PMID: 34831519 PMCID: PMC8623023 DOI: 10.3390/ijerph182211762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/01/2021] [Accepted: 11/05/2021] [Indexed: 12/02/2022]
Abstract
In Nepal, 47% of individuals who fell ill with TB were not reported to the National TB Program in 2018. Approximately 60% of persons with TB initially seek care in the private sector. From November 2018 to January 2020, we implemented an active case finding intervention in the Parsa and Dhanusha districts targeting private provider facilities. To evaluate the impact of the intervention, we reported on crude intervention results. We further compared case notification during the implementation to baseline and control population (Bara and Siraha) notifications. We screened 203,332 individuals; 11,266 (5.5%) were identified as presumptive for TB and 8077 (71.7%) were tested for TB. Approximately 8% had a TB diagnosis, of whom 383 (56.2%) were bacteriologically confirmed (Bac+). In total, 653 (95.7%) individuals were initiated on treatment at DOTS facilities. For the intervention districts, there was a 17%increase for bacteriologically positive TB and 10% for all forms TB compared to baseline. In comparison, the change in notifications in the control population were 4% for bacteriologically positive, and −2% all forms. Through engagement of private sector facilities, our intervention was able to increase the number of individuals identified with TB by over 10% in the Parsa and Dhanusha districts.
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Tran CH, Moore BK, Pathmanathan I, Lungu P, Shah NS, Oboho I, Al-Samarrai T, Maloney SA, Date A, Boyd AT. Tuberculosis treatment within differentiated service delivery models in global HIV/TB programming. J Int AIDS Soc 2021; 24 Suppl 6:e25809. [PMID: 34713974 PMCID: PMC8554213 DOI: 10.1002/jia2.25809] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 08/19/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Providing more convenient and patient‐centred options for service delivery is a priority within global HIV programmes. These efforts improve patient satisfaction and retention and free up time for providers to focus on new HIV diagnoses or severe illness. Recently, the coronavirus disease 2019 (COVID‐19) pandemic precipitated expanded eligibility criteria for these differentiated service delivery (DSD) models to decongest clinics and protect patients and healthcare workers. This has resulted in dramatic scale‐up of DSD for antiretroviral therapy, cotrimoxazole and tuberculosis (TB) preventive treatment. While TB treatment among people living with HIV (PLHIV) has traditionally involved frequent, facility‐based management, TB treatment can also be adapted within DSD models. Such adaptations could include electronic tools to ensure appropriate clinical management, treatment support, adherence counselling and adverse event (AE) monitoring. In this commentary, we outline considerations for DSD of TB treatment among PLHIV, building on best practices from global DSD model implementation for HIV service delivery. Discussion In operationalizing TB treatment in DSD models, we consider the following: what activity is being done, when or how often it takes place, where it takes place, by whom and for whom. We discuss considerations for various programme elements including TB screening and diagnosis; medication dispensing; patient education, counselling and support; clinical management and monitoring; and reporting and recording. General approaches include multi‐month dispensing for TB medications during intensive and continuation phases of treatment and standardized virtual adherence and AE monitoring. Lastly, we provide operational examples of TB treatment delivery through DSD models, including a conceptual model and an early implementation experience from Zambia. Conclusions COVID‐19 has catalysed the rapid expansion of differentiated patient‐centred service delivery for PLHIV. Expanding DSD models to include TB treatment can capitalize on existing platforms, while providing high‐quality, routine treatment, follow‐up and patient education and empowerment.
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Affiliation(s)
- Cuc H Tran
- Division ofHIV & Global Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Brittany K Moore
- Division ofHIV & Global Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ishani Pathmanathan
- Division ofHIV & Global Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Patrick Lungu
- National TB and Leprosy Programme, Ministry of Health, Lusaka, Zambia
| | - N Sarita Shah
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Ikwo Oboho
- Division ofHIV & Global Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Teeb Al-Samarrai
- Office of the Global AIDS Coordinator, U.S. State Department, Washington, DC, USA
| | - Susan A Maloney
- Division ofHIV & Global Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anand Date
- Division ofHIV & Global Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andrew T Boyd
- Division ofHIV & Global Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Souza LLL, Santos FLD, Crispim JDA, Fiorati RC, Dias S, Bruce ATI, Alves YM, Ramos ACV, Berra TZ, da Costa FBP, Alves LS, Monroe AA, Fronteira I, Arcêncio RA. Causes of multidrug-resistant tuberculosis from the perspectives of health providers: challenges and strategies for adherence to treatment during the COVID-19 pandemic in Brazil. BMC Health Serv Res 2021; 21:1033. [PMID: 34592970 PMCID: PMC8483800 DOI: 10.1186/s12913-021-07057-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multidrug-resistant tuberculosis (MDR-TB) is a serious phenomenon on a global scale that can worsen with the COVID-19 pandemic. The study aimed to understand the perceptions of health professionals about MDR-TB, their strategies to ensure adherence to treatment and their challenges in the context of the COVID-19 pandemic in a priority municipality for disease control. METHODS We conducted a qualitative study and recruited 14 health providers (four doctors, three nurses, three nursing technicians, three nursing assistants and a social worker) working in a city in the state of São Paulo, Brazil. Remote semi-structured interviews were conducted with the participants. For data analysis, the thematic content analysis technique was applied according to the study's theoretical framework. RESULTS The study revealed the causes of MDR-TB are associated with poverty, vulnerability, and social risk. A pre-judgement from the providers was observed, namely, all patients do not adhere due their resistance and association with drug abuse or alcoholism. The study also observed difficulty among health providers in helping patients reconstruct and reframe their life projects under a care perspective, which would strengthen adherence. Other issues that weakened adherence were the cuts in social protection and the benefits really necessary to the patients and a challenge for the providers manage that. The participants revealed that their actions were impacted by the pandemic and insecurity and fear manifested by patients after acquiring COVID-19. For alleviating this, medical appointments by telephone, delivery of medicine in the homes of patients and visits by health professionals once per week were provided. CONCLUSION The study advances knowledge by highlighting the challenges faced by the health system with the adherence of patients with MDR-TB in a context aggravated by the pandemic. An improvement in DOT is really necessary to help the patients reframe their lives without prejudices, face their fears and insecurity, recover their self-esteem and motivate in concluding their treatment.
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Affiliation(s)
- Ludmilla Leidianne Limirio Souza
- Master of Science, Public Health Nursing Graduate Program, University of São Paulo at Ribeirão Preto College of Nursing, Avenida dos Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, São Paulo, Brazil.
| | - Felipe Lima Dos Santos
- Master of Science, Public Health Nursing Graduate Program, University of São Paulo at Ribeirão Preto College of Nursing, Avenida dos Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, São Paulo, Brazil
| | - Juliane de Almeida Crispim
- Postdoctoral Fellowship in the Interinstitutional Doctoral Program in Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Regina Célia Fiorati
- University of São Paulo at Ribeirão Preto Medical School at Ribeirão Preto, São Paulo, Brazil
| | - Sónia Dias
- Universidade NOVA de Lisboa at National School of Public Health, Lisbon, Portugal
| | - Alexandre Tadashi Inomata Bruce
- Master of Science, Public Health Nursing Graduate Program, University of São Paulo at Ribeirão Preto College of Nursing, Avenida dos Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, São Paulo, Brazil
| | - Yan Mathias Alves
- Public Health Nursing Graduate Program, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Antônio Carlos Vieira Ramos
- Public Health Nursing Graduate Program, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Thaís Zamboni Berra
- Public Health Nursing Graduate Program, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | | | - Luana Seles Alves
- Public Health Nursing Graduate Program, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Aline Aparecida Monroe
- University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Inês Fronteira
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade NOVA de Lisboa, Lisbon, Portugal
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Telisinghe L, Ruperez M, Amofa-Sekyi M, Mwenge L, Mainga T, Kumar R, Hassan M, Chaisson L, Naufal F, Shapiro A, Golub J, Miller C, Corbett E, Burke R, MacPherson P, Hayes R, Bond V, Daneshvar C, Klinkenberg E, Ayles H. Does tuberculosis screening improve individual outcomes? A systematic review. EClinicalMedicine 2021; 40:101127. [PMID: 34604724 PMCID: PMC8473670 DOI: 10.1016/j.eclinm.2021.101127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND To determine if tuberculosis (TB) screening improves patient outcomes, we conducted two systematic reviews to investigate the effect of TB screening on diagnosis, treatment outcomes, deaths (clinical review assessing 23 outcome indicators); and patient costs (economic review). METHODS Pubmed, EMBASE, Scopus and the Cochrane Library were searched between 1/1/1980-13/4/2020 (clinical review) and 1/1/2010-14/8/2020 (economic review). As studies were heterogeneous, data synthesis was narrative. FINDINGS Clinical review: of 27,270 articles, 18 (n=3 trials) were eligible. Nine involved general populations. Compared to passive case finding (PCF), studies showed lower smear grade (n=2/3) and time to diagnosis (n=2/3); higher pre-treatment losses to follow-up (screened 23% and 29% vs PCF 15% and 14%; n=2/2); and similar treatment success (range 68-81%; n=4) and case fatality (range 3-11%; n=5) in the screened group. Nine reported on risk groups. Compared to PCF, studies showed lower smear positivity among those culture-confirmed (n=3/4) and time to diagnosis (n=2/2); and similar (range 80-90%; n=2/2) treatment success in the screened group. Case fatality was lower in n=2/3 observational studies; both reported on established screening programmes. A neonatal trial and post-hoc analysis of a household contacts trial found screening was associated with lower all-cause mortality. Economic review: From 2841 articles, six observational studies were eligible. Total costs (n=6) and catastrophic cost prevalence (n=4; range screened 9-45% vs PCF 12-61%) was lower among those screened. INTERPRETATION We found very limited patient outcome data. Collecting and reporting this data must be prioritised to inform policy and practice. FUNDING WHO and EDCTP.
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Affiliation(s)
- L Telisinghe
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | - M Ruperez
- London School of Hygiene and Tropical Medicine, London, UK
| | - M Amofa-Sekyi
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | - L Mwenge
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | - T Mainga
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | - R Kumar
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | - M Hassan
- University Hospitals Plymouth NHS Trust, UK
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Egypt
| | - L.H Chaisson
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, USA
| | - F Naufal
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, USA
| | - A.E Shapiro
- Departments of Global Health and Medicine, University of Washington, Seattle, USA
| | - J.E Golub
- Johns Hopkins University School of Medicine, Center for Tuberculosis Research, Baltimore, USA
| | - C Miller
- Global TB programme, World Health Organization, Geneva, Switzerland
| | - E.L Corbett
- London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - R.M Burke
- London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - P MacPherson
- London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - R.J Hayes
- London School of Hygiene and Tropical Medicine, London, UK
| | - V Bond
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
| | | | - E Klinkenberg
- London School of Hygiene and Tropical Medicine, London, UK
- Department of Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - H.M Ayles
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, University of Zambia School of Public Health, Ridgeway, Zambia
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Dixit K, Biermann O, Rai B, Aryal TP, Mishra G, Teixeira de Siqueira-Filha N, Paudel PR, Pandit RN, Sah MK, Majhi G, Levy J, Rest JV, Gurung SC, Dhital R, Lönnroth K, Squire SB, Caws M, Sidney K, Wingfield T. Barriers and facilitators to accessing tuberculosis care in Nepal: a qualitative study to inform the design of a socioeconomic support intervention. BMJ Open 2021; 11:e049900. [PMID: 34598986 PMCID: PMC8488704 DOI: 10.1136/bmjopen-2021-049900] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 09/10/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Psychosocial and economic (socioeconomic) barriers, including poverty, stigma and catastrophic costs, impede access to tuberculosis (TB) services in low-income countries. We aimed to characterise the socioeconomic barriers and facilitators of accessing TB services in Nepal to inform the design of a locally appropriate socioeconomic support intervention for TB-affected households. DESIGN From August 2018 to July 2019, we conducted an exploratory qualitative study consisting of semistructured focus group discussions (FGDs) with purposively selected multisectoral stakeholders. The data were managed in NVivo V.12, coded by consensus and analysed thematically. SETTING The study was conducted in four districts, Makwanpur, Chitwan, Dhanusha and Mahottari, which have a high prevalence of poverty and TB. PARTICIPANTS Seven FGDs were conducted with 54 in-country stakeholders, grouped by stakeholders, including people with TB (n=21), community stakeholders (n=13) and multidisciplinary TB healthcare professionals (n=20) from the National TB Programme. RESULTS The perceived socioeconomic barriers to accessing TB services were: inadequate TB knowledge and advocacy; high food and transportation costs; income loss and stigma. The perceived facilitators to accessing TB care and services were: enhanced championing and awareness-raising about TB and TB services; social protection including health insurance; cash, vouchers and/or nutritional allowance to cover food and travel costs; and psychosocial support and counselling integrated with existing adherence counselling from the National TB Programme. CONCLUSION These results suggest that support interventions that integrate TB education, psychosocial counselling and expand on existing cash transfer schemes would be locally appropriate and could address the socioeconomic barriers to accessing and engaging with TB services faced by TB-affected households in Nepal. The findings have been used to inform the design of a socioeconomic support intervention for TB-affected households. The acceptability, feasibility and impact of this intervention on TB-related costs, stigma and TB treatment outcomes, is now being evaluated in a pilot implementation study in Nepal.
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Affiliation(s)
- Kritika Dixit
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Olivia Biermann
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Bhola Rai
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
| | - Tara Prasad Aryal
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
| | - Gokul Mishra
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Noemia Teixeira de Siqueira-Filha
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Department of Health Sciences, University of York, York, UK
| | - Puskar Raj Paudel
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
- KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | - Ram Narayan Pandit
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
| | - Manoj Kumar Sah
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
| | - Govinda Majhi
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
| | - Jens Levy
- KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | - Job van Rest
- KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | - Suman Chandra Gurung
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Raghu Dhital
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
| | - Knut Lönnroth
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - S Bertel Squire
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Maxine Caws
- Department of Research, Birat Nepal Medical Trust (BNMT), Kathmandu, Nepal
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kristi Sidney
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
| | - Tom Wingfield
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, Sweden
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
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Costs and cost-effectiveness of a comprehensive tuberculosis case finding strategy in Zambia. PLoS One 2021; 16:e0256531. [PMID: 34499668 PMCID: PMC8428570 DOI: 10.1371/journal.pone.0256531] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/09/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Active-case finding (ACF) programs have an important role in addressing case detection gaps and halting tuberculosis (TB) transmission. Evidence is limited on the cost-effectiveness of ACF interventions, particularly on how their value is impacted by different operational, epidemiological and patient care-seeking patterns. Methods We evaluated the costs and cost-effectiveness of a combined facility and community-based ACF intervention in Zambia that utilized mobile chest X-ray with computer-aided reading/interpretation software and laboratory-based Xpert MTB/RIF testing. Programmatic costs (in 2018 US dollars) were assessed from the health system perspective using prospectively collected cost and operational data. Cost-effectiveness of the ACF intervention was assessed as the incremental cost per TB death averted over a five-year time horizon using a multi-stage Markov state-transition model reflecting patient symptom-associated care-seeking and TB care under ACF compared to passive care. Results Over 18 months of field operations, the ACF intervention costed $435 to diagnose and initiate treatment for one person with TB. After accounting for patient symptom-associated care-seeking patterns in Zambia, we estimate that this one-time ACF intervention would incrementally diagnose 407 (7,207 versus 6,800) TB patients and avert 502 (611 versus 1,113) TB-associated deaths compared to the status quo (passive case finding), at an incremental cost of $2,284 per death averted over the next five-year period. HIV/TB mortality rate, patient symptom-associated care-seeking probabilities in the absence of ACF, and the costs of ACF patient screening were key drivers of cost-effectiveness. Conclusions A one-time comprehensive ACF intervention simultaneously operating in public health clinics and corresponding catchment communities can have important medium-term impact on case-finding and be cost-effective in Zambia. The value of such interventions increases if targeted to populations with high HIV/TB mortality, substantial barriers (both behavioral and physical) to care-seeking exist, and when ACF interventions can optimize screening by achieving operational efficiency.
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Mokti K, Md Isa Z, Sharip J, Abu Bakar SN, Atil A, Hayati F, Syed Abdul Rahim SS. Predictors of delayed sputum smear conversion among pulmonary tuberculosis patients in Kota Kinabalu, Malaysia: A retrospective cohort study. Medicine (Baltimore) 2021; 100:e26841. [PMID: 34397855 PMCID: PMC8341317 DOI: 10.1097/md.0000000000026841] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT Smear-positive pulmonary tuberculosis (SPPTB) is the major contributor to the spread of tuberculosis (TB) infection, and it creates high morbidity and mortality worldwide. The objective of this study was to determine the predictors of delayed sputum smear conversion at the end of the intensive phase of TB treatment in Kota Kinabalu, Malaysia.This retrospective study was conducted utilising data of SPPTB patients treated in 5 TB treatment centres located in Kota Kinabalu, Malaysia from 2013 to 2018. Pulmonary TB (PTB) patients included in the study were those who had at least completed the intensive phase of anti-TB treatment with sputum smear results at the end of the 2nd month of treatment. The factors associated with delayed sputum smear conversion were analyzed using multiple logistic regression analysis. Predictors of sputum smear conversion at the end of intensive phase were evaluated.A total of 2641 patients from the 2013 to 2018 periods were included in this study. One hundred eighty nine (7.2%) patients were identified as having delayed sputum smear conversion at the end of the intensive phase treatment. Factors of moderate (advanced odd ratio [aOR]: 1.7) and advanced (aOR: 2.7) chest X-ray findings at diagnosis, age range of >60 (aOR: 2.1), year of enrolment 2016 (aOR: 2.8), 2017 (aOR: 3.9), and 2018 (aOR: 2.8), smokers (aOR: 1.5), no directly observed treatment short-course (DOTS) supervisor (aOR: 6.9), non-Malaysian citizens (aOR: 1.5), and suburban home locations (aOR: 1.6) were associated with delayed sputum smear conversion at the end of the intensive phase of the treatment.To improve sputum smear conversion success rate, the early detection of PTB cases has to be fine-tuned so as to reduce late or severe case presentation during diagnosis. Efforts must also be in place to encourage PTB patients to quit smoking. The percentage of patients assigned with DOTS supervisors should be increased while at the same time ensuring that vulnerable groups such as those residing in suburban localities, the elderly and migrant TB patients are provided with proper follow-up treatment and management.
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Affiliation(s)
- Khalid Mokti
- Department of Community and Family Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Zaleha Md Isa
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Julaidah Sharip
- Kota Kinabalu District Health Office, Ministry of Health Malaysia, Kota Kinabalu, Sabah, Malaysia
| | - Sahrol Nizam Abu Bakar
- Kota Kinabalu District Health Office, Ministry of Health Malaysia, Kota Kinabalu, Sabah, Malaysia
| | - Azman Atil
- Department of Community and Family Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Firdaus Hayati
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
| | - Syed Sharizman Syed Abdul Rahim
- Department of Community and Family Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
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Dongo JP, Graham SM, Nsonga J, Wabwire-Mangen F, Maleche-Obimbo E, Mupere E, Nyinoburyo R, Nakawesi J, Sentongo G, Amuge P, Detjen A, Mugabe F, Turyahabwe S, Sekadde MP, Zawedde-Muyanja S. Implementation of an Effective Decentralised Programme for Detection, Treatment and Prevention of Tuberculosis in Children. Trop Med Infect Dis 2021; 6:tropicalmed6030131. [PMID: 34287383 PMCID: PMC8293469 DOI: 10.3390/tropicalmed6030131] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 11/16/2022] Open
Abstract
Childhood tuberculosis (TB) is consistently under-detected in most high-burden countries, including Uganda, especially in young children at high risk for severe disease and mortality. TB preventive treatment (TPT) for high-risk child contacts is also poorly implemented. The centralised concentration of services for child TB at the referral level is a major challenge in the prevention, detection and treatment of TB in children. In 2015, the DETECT Child TB Project was implemented in two districts of Uganda and involved decentralisation of healthcare services for child TB from tertiary to primary healthcare facilities, along with establishing linkages to support community-based household contact screening and management. The intervention resulted in improved case finding of child and adult TB cases, improved treatment outcomes for child TB and high uptake and completion of TPT for eligible child contacts. A detailed description of the development and implementation of this project is provided, along with findings from an external evaluation. The ongoing mentorship and practical support for health workers to deliver optimal services in this context were critical to complement the use of training and training tools. A summary of the project’s outcomes is provided along with the key challenges identified and the lessons learnt.
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Affiliation(s)
- John Paul Dongo
- International Union against Tuberculosis and Lung Disease, Kampala P.O. Box 16094, Uganda; (J.P.D.); (J.N.)
| | - Stephen M. Graham
- International Union against Tuberculosis and Lung Disease, Kampala P.O. Box 16094, Uganda; (J.P.D.); (J.N.)
- Centre for International Child Health, Department of Paediatrics and Murdoch Children’s Research Institute, University of Melbourne, Royal Children’s Hospital, Melbourne 3052, Australia
- Correspondence: ; Tel.: +61-(0)405-782-505
| | - Joseph Nsonga
- International Union against Tuberculosis and Lung Disease, Kampala P.O. Box 16094, Uganda; (J.P.D.); (J.N.)
| | - Fred Wabwire-Mangen
- School of Public Health, Makerere University College of Health Sciences, Kampala P.O. Box 16094, Uganda;
| | - Elizabeth Maleche-Obimbo
- Department of Paediatrics and Child Health, School of Medicine, University of Nairobi, Nirobi P.O. Box 30197-00100, Kenya;
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala P.O. Box 7072, Uganda;
| | | | - Jane Nakawesi
- Mildmay Uganda, Kampala P.O. Box 24985, Uganda; (R.N.); (J.N.)
| | - Gerald Sentongo
- Baylor College of Medicine Children’s Foundation-Uganda, Kampala P.O. Box 72052, Uganda; (G.S.); (P.A.)
| | - Pauline Amuge
- Baylor College of Medicine Children’s Foundation-Uganda, Kampala P.O. Box 72052, Uganda; (G.S.); (P.A.)
| | | | - Frank Mugabe
- National Tuberculosis and Leprosy Program, Kampala P.O. Box 16069, Uganda; (F.M.); (S.T.); (M.P.S.)
| | - Stavia Turyahabwe
- National Tuberculosis and Leprosy Program, Kampala P.O. Box 16069, Uganda; (F.M.); (S.T.); (M.P.S.)
| | - Moorine P. Sekadde
- National Tuberculosis and Leprosy Program, Kampala P.O. Box 16069, Uganda; (F.M.); (S.T.); (M.P.S.)
| | - Stella Zawedde-Muyanja
- The Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala P.O. Box 22418, Uganda;
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Adhikari B, Pokharel S, Raut S, Adhikari J, Thapa S, Paudel K, G C N, Neupane S, Neupane SR, Yadav R, Shrestha S, Rijal KR, Marahatta SB, Cheah PY, Pell C. Why do people purchase antibiotics over-the-counter? A qualitative study with patients, clinicians and dispensers in central, eastern and western Nepal. BMJ Glob Health 2021; 6:bmjgh-2021-005829. [PMID: 33975888 PMCID: PMC8118002 DOI: 10.1136/bmjgh-2021-005829] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Over-the-counter (OTC) use of antibiotics contributes to the burgeoning rise in antimicrobial resistance (AMR). Drawing on qualitative research methods, this article explores the characteristics of OTC sales of antibiotic in Nepal, its drivers and implications for policy. Methods Data were collected in and around three tertiary hospitals in eastern, western and central Nepal. Using pre-defined guides, a mix of semi-structured interviews and focus group discussions were conducted with dispensers at drug stores, patients attending a hospital and clinicians. Interviews were audio-recorded, translated and transcribed into English and coded using a combination of an inductive and deductive approach. Results Drug shops were the primary location where patients engaged with health services. Interactions were brief and transactional: symptoms were described or explicit requests for specific medicine made, and money was exchanged. There were economic incentives for clients and drug stores: patients were able to save money by bypassing the formal healthcare services. Clinicians described antibiotics as easily available OTC at drug shops. Dispensing included the empirical use of broad-spectrum antibiotics, often combining multiple antibiotics, without laboratory diagnostic and drug susceptibility testing. Inappropriately short regimens (2–3 days) were also offered without follow-up. Respondents viewed OTC antibiotic as a convenient alternative to formal healthcare, the access to which was influenced by distance, time and money. Respondents also described the complexities of navigating various departments in hospitals and little confidence in the quality of formal healthcare. Clinicians and a few dispensers expressed concerns about AMR and referred to evadable policies around antibiotics use and poor enforcement of regulation. Conclusions The findings point to the need for clear policy guidance and rigorous implementation of prescription-only antibiotics.
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Affiliation(s)
- Bipin Adhikari
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sunil Pokharel
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Shristi Raut
- Universal College of Medical Sciences and Teaching Hospital, Bhairahawa, Nepal
| | | | - Suman Thapa
- Patan Academy of Health Sciences, Patan, Nepal
| | - Kumar Paudel
- Universal College of Medical Sciences and Teaching Hospital, Bhairahawa, Nepal
| | - Narayan G C
- Universal College of Medical Sciences and Teaching Hospital, Bhairahawa, Nepal
| | - Sandesh Neupane
- Country Coordinating Mechanism, The Global Fund, Ministry of Health and Population, Kathmandu, Nepal
| | | | - Rakesh Yadav
- Nepal Public Health Research & Development Centre, Kathmandu, Nepal
| | - Sirapa Shrestha
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
| | - Komal Raj Rijal
- Central Department of Microbiology, Tribhuvan University, Kirtipur, Nepal
| | | | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Christopher Pell
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
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Kamchedzera W, Maheswaran H, Squire SB, Joekes E, Pai M, Nliwasa M, G Lalloo D, Webb EL, Corbett EL, MacPherson P. Economic costs of accessing tuberculosis (TB) diagnostic services in Malawi: an analysis of patient costs from a randomised controlled trial of computer-aided chest x-ray interpretation. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.16683.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Patients with tuberculosis (TB) symptoms in low-resource settings face convoluted diagnostic and treatment linkage pathways, incurring substantial health-seeking costs. In the context of a randomised trial looking at the impact of novel diagnostics such as computer-aided chest x-ray diagnosis (CAD4TB), we aimed to investigate the costs incurred by patients seeking TB diagnosis and whether optimised diagnostic interventions could result in a reduction in the cost faced by households. Methods: PROSPECT was a three-arm randomised trial conducted in a public primary health clinic in Blantyre, Malawi during 2018-2019 (trial arms: standard of care [SOC]; HIV testing [HIV]; HIV testing and CAD4TB [HIV/TB]). The direct and indirect costs incurred by 219 PROSPECT participants over the 56-day follow-up period were collected. Costs were deemed catastrophic if they exceeded 20% of annual household income. We compared mean costs and used generalised linear regression models to examine whether the interventions could result in a reduction in total costs. Results: The mean total cost incurred by all 219 participants was US$12.11 (standard error (SE): 1.86). The indirect and direct cost was US$8.47 (SE: 1.66) and US$3.64 (SE: 0.38), respectively. The mean total cost composed of 5.6% of the average annual household income. In total, 5% (9/180) of the participants with complete income data incurred catastrophic costs. Compared to SOC, there was no statistically significant difference in the mean total cost faced by those in the HIV (ratio: 0.77, 95% CI: 0.51, 1.19) and HIV/TB arms (ratio: 0.85, 95% CI: 0.53, 1.37). Conclusions: Despite the absence of user fees, patients seeking healthcare with TB symptoms incurred catastrophic costs. The optimised TB diagnostic interventions that were investigated in the PROSPECT study did not significantly reduce costs. TB diagnosis interventions should be implemented alongside social protection policies whilst ensuring healthcare facilities are accessible by the poor.
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Rijal KR, Banjara MR, Dhungel B, Kafle S, Gautam K, Ghimire B, Ghimire P, Dhungel S, Adhikari N, Shrestha UT, Sunuwar DR, Adhikari B, Ghimire P. Use of antimicrobials and antimicrobial resistance in Nepal: a nationwide survey. Sci Rep 2021; 11:11554. [PMID: 34078956 PMCID: PMC8172831 DOI: 10.1038/s41598-021-90812-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 05/18/2021] [Indexed: 01/21/2023] Open
Abstract
Nepal suffers from high burden of antimicrobial resistance (AMR) due to inappropriate use of antibiotics. The main objective of this study was to explore knowledge, attitude and practices of antibiotics uses among patients, healthcare workers, laboratories, drug sellers and farmers in eight districts of Nepal. A cross-sectional survey was conducted between April and July 2017. A total of 516 individuals participated in a face-to-face interview that included clinicians, private drug dispensers, patients, laboratories, public health centers/hospitals and, livestock and poultry farmers. Out of 516 respondents, 62.8% (324/516) were patients, 16.9% (87/516) were clinicians, 6.4% (33/516) were private drug dispensers. A significant proportion of patients (42.9%; 139/324) thought that fever could be treated with antibiotics. Majority (79%; 256/324) of the patients purchased antibiotics over the counter. The knowledge of antibiotics used among patients increased proportionately with the level of education: literate only [AOR = 1.4 (95% Cl = 0.6-4.4)], versus secondary education (8-10 grade) [AOR = 1.8 (95% Cl = 1.0-3.4)]. Adult patients were more aware of antibiotic resistance. Use of antibiotics over the counter was found high in this study. Knowledge, attitude and practice related to antibiotic among respondents showed significant gaps and need an urgent effort to mitigate such practice.
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Affiliation(s)
- Komal Raj Rijal
- Central Department of Microbiology, Tribhuvan University, Kirtipur, Kathmandu, Nepal.
| | - Megha Raj Banjara
- Central Department of Microbiology, Tribhuvan University, Kirtipur, Kathmandu, Nepal
| | - Binod Dhungel
- Central Department of Microbiology, Tribhuvan University, Kirtipur, Kathmandu, Nepal
| | - Samarpan Kafle
- Central Department of Microbiology, Tribhuvan University, Kirtipur, Kathmandu, Nepal
| | - Kedar Gautam
- Central Department of Microbiology, Tribhuvan University, Kirtipur, Kathmandu, Nepal
| | - Bindu Ghimire
- Central Department of Microbiology, Tribhuvan University, Kirtipur, Kathmandu, Nepal
| | | | | | - Nabaraj Adhikari
- Central Department of Microbiology, Tribhuvan University, Kirtipur, Kathmandu, Nepal
| | | | - Dev Ram Sunuwar
- Department of Public Health, Asian College for Advance Studies, Purbanchal University, Lalitpur, Nepal
| | - Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Prakash Ghimire
- Central Department of Microbiology, Tribhuvan University, Kirtipur, Kathmandu, Nepal.
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Iwaki Y, Rauniyar SK, Nomura S, Huang MC. Assessing Factors Associated with TB Awareness in Nepal: A National and Subnational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18105124. [PMID: 34066015 PMCID: PMC8151409 DOI: 10.3390/ijerph18105124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 11/16/2022]
Abstract
Tuberculosis (TB) has still remained a serious global health threat in low- and middle-income countries in recent years. As of 2021, Nepal is one of the high TB burden countries, with an increasing prevalence of cases. This study evaluates factors associated with TB awareness in Nepal. This study uses data from the Nepal Demographic and Health Survey, a cross-sectional survey carried out from June 2016 to January 2017. Multilevel logistic regression is performed to examine the association of demographic and socioeconomic factors with TB awareness. Our findings show a high level of TB awareness in all seven provinces of Nepal. Province 5 has the highest level of awareness (98.1%) among all provinces, followed by provinces 3 and 4, while province 6 has the lowest awareness level (93.2%) compared to others. Socioeconomic factors such as wealth, education and owning a mobile phone are significantly associated with TB awareness. Socioeconomic determinants are influential factors associated with TB awareness in Nepal. The wide variation in the proportion of awareness at a regional level emphasizes the importance of formulating tailored strategies to increase TB awareness. For instance, the use of mobile phones could be an effective strategy to promote TB awareness at a regional level. This study provides valuable evidence to support further research on the contribution of information and communication technology (ICT) usage to improving TB awareness in Nepal.
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Affiliation(s)
- Yoko Iwaki
- Science, Technology and Innovation Policy Program, National Graduate Institute for Policy Studies (GRIPS), 7-22-1 Roppongi, Minato-ku, Tokyo 106-8677, Japan
- Correspondence: ; Tel.: +81-3-6439-6000
| | - Santosh Kumar Rauniyar
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (S.K.R.); (S.N.)
| | - Shuhei Nomura
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (S.K.R.); (S.N.)
- Department of Health Policy and Management, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Michael C. Huang
- SciREX Center, National Graduate Institute for Policy Studies (GRIPS), 7-22-1 Roppongi, Minato-ku, Tokyo 106-8677, Japan;
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Biermann O, Dixit K, Rai B, Caws M, Lönnroth K, Viney K. Building on facilitators and overcoming barriers to implement active tuberculosis case-finding in Nepal, experiences of community health workers and people with tuberculosis. BMC Health Serv Res 2021; 21:295. [PMID: 33794878 PMCID: PMC8015737 DOI: 10.1186/s12913-021-06290-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/16/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Nepal has a high burden of undetected tuberculosis (TB). In line with the World Health Organization's End TB Strategy, the National TB Programme promotes active case-finding (ACF) as one strategy to find people with TB who are unreached by existing health services. The IMPACT TB (Implementing proven community-based active TB case-finding intervention) project was implemented in four districts in Nepal, generating a substantial yield of previously undetected TB. We aimed to identify the facilitators and barriers linked to the implementation of ACF within IMPACT TB, as well as how those facilitators and barriers have been or could be addressed. METHODS This was an exploratory qualitative study based on 17 semi-structured key-informant interviews with people with TB who were identified through ACF, and community health workers who had implemented ACF. Thematic analysis was applied in NVivo 11, using an implementation science framework developed by Grol and Wensing to classify the data. RESULTS We generated five main themes from the data: (1) ACF addressed the social determinants of TB by providing timely access to free healthcare, (2) knowledge and awareness about TB among people with TB, communities and community health workers were the 'oil' in the ACF 'machine', (3) trust in community health workers was fundamental for implementing ACF, (4) community engagement and support had a powerful influence on ACF implementation and (5) improved working conditions and enhanced collaboration with key stakeholders could further facilitate ACF. These themes covered a variety of facilitators and barriers, which we divided into 22 categories cutting across five framework levels: innovation, individual professional, patient, social context and organizational context. CONCLUSIONS This study provides new insights into facilitators and barriers for the implementation of ACF in Nepal and emphasizes the importance of addressing the social determinants of TB. The main themes reflect key ingredients which are required for successful ACF implementation, while the absence of these factors may convert them from facilitators into barriers for ACF. As this study outlined "how-to" strategies for ACF implementation, the findings can furthermore inform the planning and implementation of ACF in Nepal and similar contexts in low- and middle-income countries.
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Affiliation(s)
- Olivia Biermann
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Tomtebodavägen 18a, 17177, Stockholm, Sweden.
| | - Kritika Dixit
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Tomtebodavägen 18a, 17177, Stockholm, Sweden
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
| | - Bhola Rai
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
| | - Maxine Caws
- Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, UK
| | - Knut Lönnroth
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Tomtebodavägen 18a, 17177, Stockholm, Sweden
| | - Kerri Viney
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Tomtebodavägen 18a, 17177, Stockholm, Sweden
- Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, Australia
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