Pragmatic Management of Drug-Resistant Tuberculosis: A Qualitative Analysis of Human Resource Constraints in a Resource-Limited Country context-Ethiopia

Drug-resistant tuberculosis care and treatment outcomes over the last 15 years in Ethiopia: Results from a mixed-method review of trends

BACKGROUND AND OBJECTIVES

Drug resistant tuberculosis (DR-TB) remains a global challenge with about a third of the cases are not detected. With the recent advances in the diagnosis and treatment follow-up of DR-TB, there have been improvements with treatment success rates. However, there is limited evidence on the successful models of care that have consistently registered good outcomes. Our aim was to assess Ethiopia's experience in scaling up an ambulatory, decentralized model of care while managing multiple regimen transition processes and external shocks.

METHODS

This was a cross-sectional, mixed-method study. For the quantitative data, we reviewed routine surveillance data for the period 2009-2022 and collected additional data from publicly available reports. We then analyzed the data descriptively. Qualitative data were collected from program reports, quarterly presentations, minutes of technical working group meetings, and clinical review committee reports and analyzed thematically.

RESULTS

The number of DR-TB treatment initiating centers increased from 1 to 67, and enrollment increased from 88 in 2010 to 741 in 2019, but declined to 518 in 2022. A treatment success rate (TSR) of over 70% was sustained. The decentralized and ambulatory service delivery remained the core service delivery model. The country successfully navigated multiple regimen transitions, including the recently introduced six-month short oral regimen. Several challenges remain, including the lack of strong and sustainable specimen transportation system, lack of established systems for timely tracing and linking of missed DR-TB cases, and data quality issues.

CONCLUSIONS

Ethiopia scaled up a decentralized ambulatory model of care, kept up to date with recent developments in treatment regimens, and maintained a high TSR, despite the influence of multiple external challenges. The recent decline in case notification requires a deeper look into the underlying reasons. The feasibility of fully integrating DR-TB treatment and follow up at community level should be explored further.

Occupational injuries and their sociodemographic, workplace, and behavioral determinants among large-scale factory workers in Ethiopia: a cross-sectional study

Workplace injuries constitute a serious and growing public health concern worldwide. Despite work-related injuries being highly common, especially among workers in the manufacturing industry, their growing complexities are not adequately addressed in the current literature. Therefore this study aims to investigate the association between sociodemographic, workplace, and behavioral characteristics with work-related injuries among large-scale factory workers in Ethiopia. A cross-sectional study was conducted from February to April 2020 with 457 workers selected from large-scale factories in Addis Ababa, the capital of Ethiopia. Survey data included sociodemographic characteristics, working and safety conditions, and behavioral factors as predictors of occupational injuries. A logistic regression model was fitted to estimate the probability of injury and identify its associated factors. The 12-month prevalence of work-related injuries was 25%. Most injuries occurred at midnight (8.8%). Factors associated with work-related injury were excessive working hours (OR = 3.26; 95%CI: 1.26-8.41), cigarette smoking (OR = 2.72; 95%CI: 1.22-6.08), and manual handling (OR = 2.30; 95%CI: 1.13-4.72). Use of personal protective equipment reduced the odds of injury (OR = 0.42; 95%CI: 0.21-0.83). Although our estimated prevalence of occupational injury was lower than that found in other studies, our findings suggest that actions on modifiable conditions must be taken to reduce the burden of workplace injuries in Ethiopia. The results could inform preparedness and policy efforts aimed at improving worker safety and health.

"I was afraid to go to the hospital": A qualitative analysis and ethical implications of the impacts of COVID-19 on the health and medical care of older adults in Ethiopia

Objective

The COVID-19 pandemic has brought severe health consequences among older adults and posed ethical challenges. The aim of this study was to explore the impacts of COVID-19 on the health and medical care of older adults in Ethiopia and associated ethical implications, regardless of older adults' COVID-19 infection status.

Methods

In this qualitative study, we followed an inductive exploratory approach based on reflexive thematic analysis. We conducted semistructured interviews between March 2021 and November 2021 with 20 older adults and 26 health professionals who were selected from healthcare facilities and communities in Ethiopia using purposive and snowball sampling techniques. We audio-recorded, transcribed, translated, and inductively analyzed the interviews using thematic analysis.

Results

Participants reported that the pandemic compromised the accessibility and quality of both COVID and non-COVID healthcare services for older adults, which negatively impacted older adults' health conditions and medical care. Moreover, participants elaborated on the health conditions and care of older patients with COVID-19 and highlighted that older COVID-19 patients often have severe health conditions, do not get adequate COVID-19 care, and may receive lower priority for admission to intensive care units compared to younger patients when resources are limited.

Conclusions

Results of this study showed that practices of COVID-19 care and measures may have led to adverse consequences such as limited availability and access to aged care in Ethiopia, which could have further health consequences on older patients. Our results contribute to a better understanding of ethical issues such as distributive justice and prioritization arising in the healthcare of older patients in times of global pandemic. It is imperative for local and international health policymakers and ethicists to further analyze and address the challenges that compromise the accessibility and continuity of quality care for older persons during a public healthcare crisis.

Patterns of childhood tuberculosis diagnosis in Ethiopia: A multicenter cross-sectional study

Background

Children share 12% of the global 10 million people infected with tuberculosis (TB) each year. Closing case detection gap in children remains difficult, with 56% of all children and 65% under-five with TB missed each year. We aimed to assess the patterns of childhood TB diagnosis and underlying determinants in Ethiopia when different TB diagnostic platforms are applied.

Methods

A multi-site, cross-sectional study was carried out in Ethiopia as part of the larger EXIT-TB study - evidence-based multiple focused integrated intensified TB screening package. Outpatient children aged ≤ 15 with cough of any duration seeking care at four healthcare facilities in Ethiopia were enrolled consecutively. Participants underwent sputum Xpert MTB/RIF and/or smear microscopy and posteroanterior chest X-ray (CXR), and their clinical and sociodemographic data were captured using a structured questionnaire. Data were analyzed using Stata version 23. Multiple regression model was computed to determine the factors that influence TB case detection, with a 95% confidence interval (CI) and p < 0.05 taken as statistically significant.

Results

A total of 438 children were enrolled. Of these, 399 had CXR examination of which 55 (13.8%) were suggestive of TB, 270 had Xpert MTB/RIF testing of which 32 (11.9%) were positive, and AFB smear microscopy was done for 51 children of which 2 (3.9%) were positive. Febrile children were more likely to be diagnosed with pulmonary TB than those without fever [aPR = 1.3, 95% CI (1.1-1.4)], and those with a TB contact history were more likely to be diagnosed with pulmonary TB than those with no such contacts [aPR = 1.2, 95% CI (1.1-1.3)]. Children from rural residences were more likely to be diagnosed with TB than those from urban residences [aPR = 1.3, 95% CI (1.1-1.5)].

Conclusion

The findings showed that clinical diagnosis remains an important method of TB diagnosis in children and the preferred choice to avert underdiagnosis. A more sensitive TB diagnostic method for children was symptom screening, followed by CXR and Xpert MTB/RIF assay or smear microscopy. Hence, an algorithm that combines clinical, CXR, and microbiological confirmatory tests can improve the rate of pulmonary TB diagnosis in children till more accurate and cost-effective diagnostic tools are accessible. Fever, weight loss, and TB contact history are highly associated with TB positivity rates in children.

Lived experiences of patients and families with decentralised drug-resistant tuberculosis care in the Eastern Cape, South Africa

BACKGROUND

South Africa adopted the decentralised Drug Resistant Tuberculosis (DR-TB) care model in 2011 with a view of improving clinical outcomes.

AIM

This study explores the experiences and perceptions of patients and family members on the effectiveness of a decentralised community DR-TB care model in the Oliver Reginald Kaizana (OR) Tambo district municipality of the Eastern Cape, South Africa.

METHOD

In this phenomenological qualitative research design, a semi-structured interview with prompts was conducted on 30 participants (15 patients and 15 family members). Framework approach to thematic content analysis was adopted for qualitative data analysis.

RESULTS

Four themes emerged from the patients' interviews: adequate knowledge of DR-TB and its transmission, fear of death and isolation, long travel distances, and exorbitant transportation cost. A 'ready' health system influenced the effectiveness of community DR-TB management, while interviews with family members yielded five themes: misconceptions about DR-TB, rapid diagnosis and adherence counselling, long travel distances, activated healthcare workers, and little role of traditional healer.

CONCLUSION

A perceived effectiveness of a community DR-TB care model in the OR Tambo district was demonstrated through the quality and comprehensiveness of care rendered by a 'ready' health system with activated health care workers (HCWs) who provided robust support and adequate knowledge of DR-TB and its treatment/side effects. However, misconceptions about DR-TB, long travel distances to treatment facilities, high cost of transportation and stigma remained challenging for most patients and family members.Contribution: This study provides insight into the lived experiences of a decentralised community DR-TB care model in the OR Tambo district in 2020.

Risk factors for multidrug-resistant tuberculosis in the Central African Republic: A case-control study

BACKGROUND

The emergence and spread of multidrug-resistant tuberculosis (MDR-TB) presents a challenge to the "End TB by 2035" strategy. This study aimed to identify the risk factors associated with MDR-TB in patients admitted to the pneumo-physiology clinic of the National University Hospital of Bangui in Central African Republic.

METHODS

This was a "retrospective" chart review study. Cases were represented by patients more than 18 years of age treated for MDR-TB and controls were patients with "at least rifampicin-susceptible" TB treated "with first-line anti-TB regimen" and who at the end of treatment were declared cured. The status of "cured" was exclusively applicable to non-MDR TB. Risk factors associated with MDR-TB were identified by multivariate analysis.

RESULTS

We included 70 cases and 140 controls. The median age was 35 years, IQR (22;46 years). The main factors associated with the occurrence of MDR-TB in multivariate analysis were male gender (0 R = 3.02 [1.89-3.99], p = 0.001), residence in a peri-urban/urban area (0 R = 3.06 [2.21-4.01], p = 0.002), history of previous TB treatment (0 R= 3.99 [2.77-4.25], p < 0.001) and the presence of multidrug-resistant TB in the family (0 R=1.86 [1.27-2.45], p = 0.021).

CONCLUSION

The emergence of MDR-TB can be reduced by implementing appropriate strategies, such as preventive therapy in contacts of MDR-TB patients and detecting and appropriately treating MDR-TB patients to prevent further spread of infection.

Patient-reported usability and satisfaction with electronic medication event reminder and monitor device for tuberculosis: a multicentre, randomised controlled trial

Background

The success of a tuberculosis digital adherence technology relies on patients' satisfaction with and the usability of the technology. This study aimed to evaluate treatment satisfaction and usability of a digital medication event reminder and monitor (MERM) device for patients with tuberculosis to address the prespecified secondary endpoint of the SELFTB trial.

Methods

In this multicenter, randomised controlled trial, adults (≥18 years) with new or previously treated, bacteriologically-confirmed, drug-sensitive pulmonary tuberculosis who were eligible to start anti-tuberculosis therapy were recruited from 10 healthcare facilities in Ethiopia. With a computer-generated random number sequence, participants were randomly assigned 1:1 to receive a 15-day tuberculosis medication supply dispensed with an evriMED500® MERM device to self-administer and return every 15 days or the standard in-person DOT. Both arms were followed throughout the standard two-month intensive treatment phase. Treatment was based on the WHO-recommended two-month fixed-dose-combination of first-line anti-tuberculosis drug delivered as a single daily dose (2RHZE). Treatment Satisfaction Questionnaire for Medication version 4 (TSQM 1.4©) was used to measure and compare treatment satisfaction between arms. Adapted System Usability Scale (SUS) was used to assess the usability of the device, with emphasis on ease of use, challenges, benefits, motivation, popularity, and recommendation. The findings were correlated with adherence and clinical endpoints including sputum smear conversion and IsoScreen urine isoniazid test results. This trial is registered with ClinicalTrials.gov, NCT04216420.

Findings

Between June 2, 2020, and June 15, 2021, 337 patients were screened for eligibility, of whom 109 participants enrolled and completed the satisfaction [control (n = 57) and intervention (n = 52) arms] and usability [intervention arm (n = 52)] questionnaires. TSQM 1.4© geometric mean scores were: Effectiveness 73.25 [geometric standard deviation (GSD) 1.28], Side Effects 100, Convenience 63.31 (GSD 1.45), and Global Satisfaction 77.29 (GSD 1.25). TSQM score was significantly higher in the intervention vs the control: Effectiveness [85.78 vs 63.43, 95% CI 1.35 (1.26-1.45), p < 0.001], Convenience [85.41 vs 48.18, 95% CI 1.77 (1.63-1.93), p < 0.001], and Global Satisfaction [90.19 vs 67.11, 95% CI 1.34 (1.26-1.43), p < 0.001]. There were significant associations between Global Satisfaction and medication adherence (p = 0.017). Average SUS score was 97.45%, which was close to the best imaginable SUS value of 100%. Likelihood to Recommend (LTR) value was ≥9, on a scale of 0-10, for 90.4% of MERM users, yielding higher net promoters. There was no significant association between usability and medication adherence (p = 0.691).

Interpretation

Our findings suggested that treatment satisfaction scores were superior in the intervention vs control arms and across the domains of Effectiveness, Convenience, and Global Satisfaction. There was excellent usability of the MERM device and a significantly higher number of users likely to promote the device. High tuberculosis burden countries may transform patient-centered care through ongoing evaluation and scale-up of digital health innovations.

Funding

U.S. National Institute of Health (NIH) Fogarty International Center and National Institute of Allergy and Infectious Diseases (D43 TW009127) and the Emory Center for AIDS Research (P30 AI050409).

Bioethical Implications of Vulnerability and Politics for Healthcare in Ethiopia and The Ways Forward

Vulnerability and politics are among the relevant and key topics of discussion in the Ethiopian healthcare context. Attempts by the formal bioethics structure in Ethiopia to deliberate on ethical issues relating to vulnerability and politics in healthcare have been limited, even though the informal analysis of bioethical issues has been present in traditional Ethiopian communities. This is reflected in religion, social values, and local moral underpinnings. Thus, the aim of this paper is to discuss the bioethical implications of vulnerability and politics for healthcare in Ethiopia and to suggest possible ways forward. First, we will briefly introduce what has been done to develop bioethics as a field in Ethiopia and what gaps remain concerning its implementation in healthcare practice. This will give a context for our second and main task - analyzing the healthcare challenges in relation to vulnerability and politics and discussing their bioethical implications. In doing so, and since these two concepts are intrinsically broad, we demarcate their scope by focusing on specific issues such as poverty, gender, health governance, and armed conflicts. Lastly, we provide suggestions for the ways forward.

Effectiveness of a digital medication event reminder and monitor device for patients with tuberculosis (SELFTB): a multicenter randomized controlled trial

BACKGROUND

Tuberculosis remains the leading cause of death from a single infectious disease worldwide. Trials evaluating digital adherence technologies for tuberculosis in low- and middle-income countries are urgently needed. We aimed to assess whether a digital medication event reminder and monitor (MERM) device-observed self-administered therapy improves adherence and treatment outcomes in patients with tuberculosis compared with the standard in-person directly observed therapy (DOT).

METHODS

We did a two-arm, attention-controlled, effectiveness-implementation type 2 hybrid, randomized controlled trial in ten healthcare facilities in Addis Ababa, Ethiopia. We included adults with new or previously treated, bacteriologically confirmed, drug-sensitive pulmonary tuberculosis who were eligible to start anti-tuberculosis therapy. Participants were randomly assigned (1:1) to receive a 15-day tuberculosis medication supply in the evriMED500® MERM device to self-administer and return every 15 days (intervention arm) or visit the healthcare facilities each day to swallow their daily dose with DOT by healthcare providers (control arm). Both arms were followed throughout the standard two-month intensive treatment phase (2RHZE). For control participants, some provider-approved take-home doses might be allowed for extenuating circumstances in real-world practice. Data were collected on patient information (demographic, socioeconomic, behavioral, social, and clinical information), medication adherence measures (MERM vs. DOT records, IsoScreenTM urine colorimetric isoniazid test, and adherence self-report), and clinical measures (pre-post treatment sputum Xpert MTB/RIF assay or microscopy, and adverse treatment outcomes). The intention-to-treat (ITT) primary endpoints were (1) individual-level percentage adherence over the two-month intensive phase measured by adherence records compiled from MERM device vs. DOT records that also considered all take-home doses as having been ingested and (2) sputum smear conversion following the standard two-month intensive phase treatment. Secondary endpoints were (1) individual-level percentage adherence over the two-month intensive phase measured by adherence records compiled from the MERM device vs. DOT records that considered all take-home doses as not ingested, (2) negative IsoScreen urine isoniazid test, (3) adverse treatment outcome (having at least one of the three events: treatment not completed; death; or loss to follow-up), and (4) self-reported adherence. The MERM device has an electronic module and a medication container that records adherence, stores medication, emits audible and visual on-board alarms to remind patients to take their medications on time and refill, and enables providers to download the data and monitor adherence.

RESULTS

Participants were enrolled into the study between 02 June 2020 and 15 June 2021, with the last participant completing follow-up on 15 August 2021. A total of 337 patients were screened for eligibility, of whom 114 were randomly assigned and included in the final analysis [57 control and 57 intervention participants]. Participants were 64.9% male, 15% with HIV, 10.5% retreatment, and 5.3% homeless. Adherence to TB medication was comparable between the intervention arm [geometric mean percentage (GM%) 99.01%, geometric standard deviation (GSD) 1.02] and the control arm [GM% 98.97%, GSD 1.04] and was within the prespecified margin for non-inferiority [mean ratio (MR) 1.00 (95% CI 0.99-1.01); p = 0.954]. The intervention arm was significantly superior to the control arm in the secondary analysis that considered all take-home doses in the control were not ingested [control GM% 77.71 (GSD 1.57), MR 1.27 (95% CI 1.33-1.43)]. Urine isoniazid testing was done on 443 (97%) samples from 114 participants; 13 participants had at least one negative result; a negative test was significantly more common among the control group compared with the intervention group [11/57 (19.3%) vs 2/57 (3.5%); p = 0.008]. There was no significant difference between the control and intervention arms for smear conversion [55 (98.2%) vs 52 (100%); p>0.999], adverse treatment outcomes [0 vs 1 (1.9%); p = 0.48], and self-report non-adherence [5 (8.9%) vs 1 (1.9%); p = 0.21].

CONCLUSIONS

In this randomized trial of patients with drug-sensitive pulmonary tuberculosis, medication adherence among participants assigned to MERM-observed self-administered therapy was non-inferior and superior by some measures when compared with the standard in-person DOT. Further research is needed to understand whether adherence in the intervention is primarily driven by allowing self-administered therapy which reduced challenges of repeated clinic visits or by the adherence support provided by the MERM system. To avoid contributing to patient barriers with DOT, tuberculosis medical programs should consider alternatives such as medication event monitors.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04216420.

Effect of Digital Medication Event Reminder and Monitor-Observed Therapy vs Standard Directly Observed Therapy on Health-Related Quality of Life and Catastrophic Costs in Patients With Tuberculosis: A Secondary Analysis of a Randomized Clinical Trial

Importance

Little is known about whether digital adherence technologies are economical for patients with tuberculosis (TB) in resource-constrained settings.

Objective

To test the hypothesis that for patients with TB, a digital medication event reminder monitor (MERM)-observed therapy provides higher health-related quality of life (HRQoL) and lower catastrophic costs compared with standard directly observed therapy (DOT).

Design, Setting, and Participants

This study was a secondary analysis of a randomized, 2-arm, open-label trial conducted in 10 health care facilities in Ethiopia. Eligible participants were adults with new or previously treated, bacteriologically confirmed, drug-sensitive pulmonary TB who were eligible to start first-line anti-TB therapy. Participants were enrolled between June 2, 2020, and June 15, 2021, with the last participant completing follow-up on August 15, 2021.

Interventions

Participants were randomly assigned (1:1) to receive a 15-day TB medication supply dispensed with a MERM device to self-administer and return every 15 days (intervention arm) or the standard in-person DOT (control arm). Both groups were observed throughout the standard 2-month intensive treatment phase.

Main Outcomes and Measures

Prespecified secondary end points of the original trial were HRQoL using the EuroQoL 5-dimension 5-level (EQ-5D-5L) tool and catastrophic costs, direct (out-of-pocket) and indirect (guardian and coping) costs from the individual patient perspective using the World Health Organization's Tool to Estimate Patient Costs, and common factors associated with lower HRQoL and higher catastrophic costs.

Results

Among 337 patients screened for eligibility, 114 were randomly assigned, and 109 were included in the final complete-case intention-to-treat analysis (57 control and 52 intervention participants). The mean (SD) age was 33.1 (11.1) years; 72 participants (66.1%) were men, and 15 (13.9%) had HIV coinfection. EQ-5D-5L overall median (IQR) index value was 0.964 (0.907-1). The median (IQR) value was significantly higher in intervention (1 [0.974-1]) vs control (.908 [0.891-0.964]) (P < .001). EQ-5D-5L minimum and maximum health state utility values in intervention were 0.906 and 1 vs 0.832 and 1 in control. Patients' overall median (IQR) postdiagnosis cost was Ethiopian birr (ETB) 80 (ETB 16-ETB 480) (US $1.53). The median cost was significantly lower in intervention (ETB 24 [ETB 16-ETB 48]) vs control (ETB 432 [ETB 210-ETB 1980]) (P < .001), with median possible cost savings of ETB 336 (ETB 156-ETB 1339) (US $6.44) vs the control arm. Overall, 42 participants (38.5%; 95% CI, 29.4%-48.3%) faced catastrophic costs, and this was significantly lower in the intervention group (11 participants [21.2%]; 95% CI, 11.1%-34.7%) vs control (31 participants [54.4%]; 95% CI, 40.7%-67.6%) (P < .001). Trial arm was the single most important factor in low HRQoL (adjusted risk ratio [ARR], 1.49; 95% CI, 1.35-1.65; P < .001), while trial arm (ARR, 2.55; 95% CI, 1.58-4.13; P < .001), occupation (ARR, 2.58; 95% CI, 1.68-3.97; P < .001), number of cohabitants (ARR, 0.64; 95% CI, 0.43-0.95; P = .03), and smoking (ARR, 2.71; 95% CI, 1.01-7.28; P = .048) were the most important factors in catastrophic cost.

Conclusions and Relevance

In patients with TB, MERM-observed therapy was associated with higher HRQoL and lower catastrophic costs compared with standard DOT. Patient-centered digital health technologies could have the potential overcoming structural barriers to anti-TB therapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT04216420.

Validity of InterVA model versus physician review of verbal autopsy for tracking tuberculosis-related mortality in Ethiopia

BACKGROUND

In most African countries where a legitimate vital registration system is lacking, physicians often review verbal autopsy (VA) data to determine the cause of death, while there are concerns about the routine practicality, accuracy, and reliability of this procedure. In Ethiopia where the burden of tuberculosis (TB) remains unacceptably high, reliable VA data are needed to guide intervention strategies. This study aimed to validate the InterVA model against the physician VA in tracking TB-related mortality in Ethiopia.

METHODS

From a sample of deaths in Addis Ababa, Ethiopia, VAs were conducted on TB-related mortality, physician-certified verbal autopsy (PCVA) through multiple steps to ascertain the causes of death. InterVA model was used to interpret the causes of death. Estimates of TB-related deaths between physician reviews and the InterVA model were compared using Cohen's Kappa (k), Receiver-operator characteristic (ROC) curve analysis, sensitivity, and specificity to compare agreement between PCVA and InterVA.

RESULTS

A total of 8952 completed PCVA were used. The InterVA model had an optimal likelihood cut-off point sensitivity of 0.64 (95% CI: 59.0-69.0) and specificity of 0.95 (95% CI: 94.9-95.8). The area under the ROC curve was 0.79 (95% CI: 0.78-0.81). The level of agreement between physician reviews and the InterVA model to identifying TB-related mortality was moderate (k = 0.59, 95% CI: 0.57-0.61).

CONCLUSION

The InterVA model is a viable alternative to physician review for tracking TB-related causes of death in Ethiopia. From a public health perspective, InterVA helps to analyze the underlying causes of TB-related deaths cost-effectively using routine survey data and translate to policies and strategies in resource-constrained countries.

Capacity and Readiness Assessment of Healthcare Facilities for Digital Health Interventions Against Tuberculosis and HIV in Addis Ababa, Ethiopia

Background

There is a high level of concern that low-income countries lack the capacity and readiness to effectively adopt, implement, and scale up digital health interventions (DHIs). We aimed to assess the infrastructure and human resource capacity and readiness of healthcare facilities to adopt and implement any new DHI for tuberculosis (TB) and HIV care and treatment in Addis Ababa, Ethiopia.

Method

We carried out a cross-sectional, mixed-methods study in 14 public healthcare facilities that provide TB and HIV care and treatment services. Providers' perceived readiness to adopt and implement digital health was assessed using a self-administered questionnaire designed based on an adapted eHealth readiness assessment model that covers six domains: core readiness, organizational cultural readiness, value proposition readiness, technological readiness, regulatory policy readiness, and operational resource readiness. The infrastructure and human resource capacity were assessed on-site using a tool adapted from the Technology Infrastructure Checklist. Internal consistency was assessed using Cronbach's alpha, and the significant relationship between the composite variables was assessed using Pearson's correlation coefficients (r).

Result

We assessed 14 facilities on-site and surveyed 60 TB and HIV healthcare providers. According to Cronbach's alpha test, all the six technology acceptance domains had a value of >0.8, suggesting a strong interrelatedness between the measuring items. The correlation between technological readiness and operational resource readiness was significant (r = 0.8). The providers perceived their work environment as good enough in electronic data protection, while more efforts are needed in planning, training, adapting, and implementing digital health. Of the 14 facilities, 64.3% lack the plan to establish a functional local area network, and 43% lack skilled staff on payroll to provide maintenance of computers and other digital technologies.

Conclusion

Like many developing countries, there was a modest infrastructure and human resource capacity and readiness of public healthcare facilities in Addis Ababa, Ethiopia, to nurture and strengthen DHIs across the TB and HIV cascades of care. Technological and operational resource readiness, including funding and a Well-trained workforce, are essential for successful implementation and use of digital health against the two infectious diseases of global importance in such settings.

Tuberculosis Prevalence and Predictors Among Health Care-Seeking People Screened for Cough of Any Duration in Ethiopia: A Multicenter Cross-Sectional Study

Background

Tuberculosis (TB) remains a major cause of morbidity and mortality in sub-Saharan Africa. This high burden is mainly attributed to low case detection and delayed diagnosis. We aimed to determine the prevalence and predictors of TB among health care-seeking people screened for cough of any duration in Ethiopia.

Methods

In this multicenter cross-sectional study, we screened 195,713 (81.2%) for cough of any duration. We recruited a sample of 1,853 presumptive TB (PTB) cases and assigned them into three groups: group I with cough ≥2 weeks, group II with cough of <2 weeks, and group III pregnant women, patients on antiretroviral therapy, and patients with diabetes. The first two groups underwent chest radiograph (CXR) followed by sputum Xpert MTB/RIF assay or smear microscopy. The third group was exempted from CXR but underwent sputum Xpert MTB/RIF assay or smear microscopy. TB prevalence was calculated across the groups and TB predictors were analyzed using modified Poisson regression to compute adjusted prevalence ratio (aPR) with a 95% confidence interval (CI).

Results

The overall prevalence of PTB was 16.7% (309/1853). Of the positive cases, 81.2% (251/309) were in group I (cough ≥2 weeks), 14.2% (44/309) in group II (cough of <2), and 4.5% (14/309) in group III (CXR exempted). PTB predictors were age group of 25-34 [aPR = 2.0 (95% CI 1.3-2.8)], history of weight loss [aPR = 1.2 (95% CI 1.1-1.3)], and TB suggestive CXRs [aPR = 41.1 (95% CI 23.2-72.8)].

Conclusion

The prevalence of confirmed PTB among routine outpatients was high, and this included those with a low duration of cough who can serve as a source of infection. Screening all patients at outpatient departments who passively report any cough irrespective of duration is important to increase TB case finding and reduce TB transmission and mortality.

Challenges in providing ethically competent health care to incarcerated older adults with mental illness: a qualitative study exploring mental health professionals' perspectives in Canada

BACKGROUND

The population of incarcerated older adults is the fastest growing demographic in prisons. Older persons in custody have poorer health as compared with those in the community. The unmet and complex health care needs of incarcerated older adults with mental illness raise justice, safety, dignity and fairness in care as ethical concerns. As there exists research gap to better understand these concerns, the current study aimed at exploring the perspectives of mental health professionals on challenges in delivering ethically competent care to mentally ill incarcerated older adults in Canada.

METHODS

Thirty-four semi-structured interviews were conducted between August 2017 and November 2018 with prison mental health professionals in Canada who were selected using purposive and convenience sampling techniques. The audio recorded interviews were transcribed verbatim and analysed inductively to generate themes.

RESULTS

The results were distilled into three main categories and seven subcategories that related to ethical issues in the provision of health care for mentally ill incarcerated older adults. The main categories included imprisoned older persons with special care needs, lack of resources, and the peer-support program.

CONCLUSIONS

Results of this study showed that existing practices of care of mentally ill incarcerated older adults are characterised by challenges that increase their vulnerability to worse health conditions. It is imperative for local authorities, policy makers and representatives to prepare for and respond to the challenges that compromise ethically competent health care for, and healthy ageing of, mentally ill incarcerated older adults.

Real-Time Impact of COVID-19 on Clinical Care and Treatment of Patients with Tuberculosis: A Multicenter Cross-Sectional Study in Addis Ababa, Ethiopia

Background:

There were global concerns and predictions that Coronavirus disease 2019 (COVID-19) would severely affect tuberculosis (TB) care and treatment services in resource-constrained countries. This study aimed to assess the real-time impact of COVID-19 on clinical care and treatment of patients with TB in Addis Ababa, Ethiopia.

Methods:

This was a facility-based, multicenter, cross-sectional study conducted in 10 health centers with high TB clients in Addis Ababa, Ethiopia. Participants were patients with TB who have been attending TB clinical care and treatment in the COVID-19 pandemic period. Data were collected using adapted, interviewer-administered questionnaires to investigate the impact of COVID-19 in their routine care and treatment.

Result:

The study included a total of 212 consented participants. Study participants who missed appointments for medication refill were 40 (18.9%). The most important predictors of missed appointments were fear of COVID-19 [AOR = 4.25, 95% CI (1.710–25.446)], transport disruption [AOR = 8.88, 95% CI (1.618–48.761)], lockdown [AOR = 6.56, 95% CI (1.300–33.131)], traveling costs [AOR = 10.26, 95% CI (1.552–67.882)], and personal protective equipment costs [AOR = 11.15, 95% CI (2.164–57.437)]. The most costly COVID-19 preventive measures that caused financial burden to the patients were face mask [107 (50.5%)], disinfectant [106 (50%)], and sop [50 (23.6%)]. The participants were well aware of the recommended COVID-19 preventive measures. Their perceived most effective preventive measures were the use of face mask (90.1%), frequent hand washing with soap and use of disinfectant (83.0%), avoid touching eyes, nose and mouth with unwashed hands (77.8%), and stay at home (75.5%).

Conclusions:

COVID-19 significantly hampered the clinical care and treatment of patients with TB. The impact was primarily on their appointments for scheduled medication refills, clinical follow-ups, and laboratory follow-ups. Fear of getting infected with COVID-19, limited access to transportation, reduced income for traveling to health facilities, costs for personal protective equipment and traveling to healthcare facilities, and the lockdown were the major determinants. The impact could be mitigated by reducing the number of visits, rationing personal protective equipment as feasible, compensating travel expenses, providing health educations and community-based TB services, and maintaining TB services.