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Kerschberger B, Daka M, Shongwe B, Dlamini T, Ngwenya S, Danbakli C, Mamba B, Nxumalo B, Sibanda J, Dube S, Dlamini LM, Mabhena E, Mukooza E, Crumley I, Ciglenecki I, Vambe D. The introduction of video-enabled directly observed therapy (video-DOT) for patients with drug-resistant TB disease in Eswatini amid the COVID-19 pandemic - a retrospective cohort study. BMC Health Serv Res 2024; 24:699. [PMID: 38831356 PMCID: PMC11145825 DOI: 10.1186/s12913-024-11151-4] [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: 07/03/2023] [Accepted: 05/28/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Video-enabled directly observed therapy (video-DOT) has been proposed as an additional option for treatment provision besides in-person DOT for patients with drug-resistant TB (DRTB) disease. However, evidence and implementation experience mainly originate from well-resourced contexts. This study describes the operationalization of video-DOT in a low-resourced setting in Eswatini facing a high burden of HIV and TB amid the emergence of the COVID-19 pandemic. METHODS This is a retrospectively established cohort of patients receiving DRTB treatment during the implementation of video-DOT in Shiselweni from May 2020 to March 2022. We described intervention uptake (vs. in-person DOT) and assessed unfavorable DRTB treatment outcome (death, loss to care) using Kaplan-Meier statistics and multivariable Cox-regression models. Video-related statistics were described with frequencies and medians. We calculated the fraction of expected doses observed (FEDO) under video-DOT and assessed associations with missed video uploads using multivariable Poisson regression analysis. RESULTS Of 71 DRTB patients eligible for video-DOT, the median age was 39 (IQR 30-54) years, 31.0% (n = 22) were women, 67.1% (n = 47/70) were HIV-positive, and 42.3% (n = 30) were already receiving DRTB treatment when video-DOT became available. About half of the patients (n = 37; 52.1%) chose video-DOT, mostly during the time when COVID-19 appeared in Eswatini. Video-DOT initiations were lower in new DRTB patients (aHR 0.24, 95% CI 0.12-0.48) and those aged ≥ 60 years (aHR 0.27, 95% CI 0.08-0.89). Overall, 20,634 videos were uploaded with a median number of 553 (IQR 309-748) videos per patient and a median FEDO of 92% (IQR 84-97%). Patients aged ≥ 60 years were less likely to miss video uploads (aIRR 0.07, 95% CI 0.01-0.51). The cumulative Kaplan-Meier estimate of an unfavorable treatment outcome among all patients was 0.08 (95% CI 0.03-0.19), with no differences detected by DOT approach and other baseline factors in multivariable analysis. CONCLUSIONS Implementing video-DOT for monitoring of DRTB care provision amid the intersection of the HIV and COVID-19 pandemics seemed feasible. Digital health technologies provide additional options for patients to choose their preferred way to support treatment taking, thus possibly increasing patient-centered health care while sustaining favorable treatment outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Bheki Mamba
- National TB Control Programme (NTCP), Manzini, Eswatini
| | | | - Joyce Sibanda
- National TB Control Programme (NTCP), Manzini, Eswatini
| | - Sisi Dube
- National TB Control Programme (NTCP), Manzini, Eswatini
| | | | | | | | | | | | - Debrah Vambe
- National TB Control Programme (NTCP), Manzini, Eswatini
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Alves CMDS, Amaral TDS, Rezende FR, Galdino H, Guimarães RA, Costa DDM, Tipple AFV. Factors associated with Community Health Agents' knowledge about tuberculosis. Rev Bras Enferm 2024; 77:e20220520. [PMID: 38747808 PMCID: PMC11095909 DOI: 10.1590/0034-7167-2022-0520] [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: 01/09/2022] [Accepted: 11/29/2023] [Indexed: 05/18/2024] Open
Abstract
OBJECTIVE To analyze the factors associated with the knowledge of Community Health Agents (ACS) about tuberculosis. METHODS A cross-sectional study was conducted with 110 ACS. A questionnaire was used to assess knowledge about pulmonary tuberculosis (component 1) and the work functions of ACS in the National Tuberculosis Control Program (component 2). The level of knowledge, according to the scores converted into a scale of 0 to 100, was classified as: 0-50% (low), 51-75% (medium), and over 75% (high). Multiple regression was used in the analysis of associated factors. RESULTS The global score (average of the scores of components 1 and 2) median knowledge was 68.6%. Overall knowledge about tuberculosis was positively associated with the length of professional experience, having received training on tuberculosis, and access to the tuberculosis guide/handbook. CONCLUSIONS Investments in training and capacity-building strategies for ACS will contribute to increasing these professionals' knowledge, resulting in greater success in tuberculosis control.
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Affiliation(s)
| | | | | | - Hélio Galdino
- Universidade Federal de Goiás. Goiânia, Goiás, Brazil
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Peresu E, De Graeve D, Heunis JC, Kigozi NG. Cost-consequence analysis of ambulatory clinic- and home-based multidrug-resistant tuberculosis management models in Eswatini. PLoS One 2024; 19:e0301507. [PMID: 38564589 PMCID: PMC10986922 DOI: 10.1371/journal.pone.0301507] [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: 02/21/2022] [Accepted: 03/15/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND We compared the cost-consequence of a home-based multidrug-resistant tuberculosis (MDR-TB) model of care, based on task-shifting of directly observed therapy (DOT) and MDR-TB injection administration to lay health workers, to a routine clinic-based strategy within an established national TB programme in Eswatini. METHODS Data on costs and effects of the two ambulatory models of MDR-TB care was collected using documentary data and interviews in the Lubombo and Shiselweni regions of Eswatini. Health system, patient and caregiver costs were assessed in 2014 in US$ using standard methods. Cost-consequence was calculated as the cost per patient successfully treated. RESULTS In the clinic-based and home-based models of care, respectively, a total of 96 and 106 MDR-TB patients were enrolled in 2014, with treatment success rates of 67.8% and 82.1%. Health system costs per patient treated were slightly lower in the home-based strategy (US$19 598) compared to the clinic-based model (US$20 007). The largest costs in both models were for inpatient care, administration of DOT and injectable treatment, and drugs. Costs incurred by patients and caregivers were considerably higher in the clinic-based model of care due to the higher direct travel costs to the nearest clinic to receive DOT and injections daily. In total, MDR patients in the clinic-based strategy incurred average costs of US$670 compared to US$275 for MDR-TB patients in the home-based model. MDR-TB patients in the home-based programme, where DOT and injections was provided in their homes, only incurred out-of-pocket travel expenses for monthly outpatient treatment monitoring visits averaging US$100. The cost per successfully treated patient was US$31 106 and US$24 157 in the clinic-based and home-based models of care, respectively. The analysis showed that, in addition to the health benefits, direct and indirect costs for patients and their caregivers were lower in the home-based care model. CONCLUSION The home-based strategy used less resources and generated substantial health and economic benefits, particularly for patients and their caregivers, and decision makers can consider this approach as an alternative to expand and optimise MDR-TB control in resource-limited settings. Further research to understand the appropriate mix of treatment support components that are most important for optimal clinical and public health outcomes in the ambulatory home-based model of MDR-TB care is necessary.
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Affiliation(s)
- Ernest Peresu
- Centre for Development Support, Faculty of Economic and Management Sciences, University of the Free State, Bloemfontein, South Africa
| | - Diana De Graeve
- Faculty of Business and Economics, University of Antwerp, Antwerp, Belgium
| | - J. Christo Heunis
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
| | - N. Gladys Kigozi
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
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Dlamini SB, Hlongwana KW, Ginindza TG. Lung cancer awareness training experiences of community health workers in KwaZulu-Natal, South Africa. Afr J Prim Health Care Fam Med 2022; 14:e1-e9. [PMID: 36546485 PMCID: PMC9772754 DOI: 10.4102/phcfm.v14i1.3414] [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: 12/28/2021] [Revised: 07/21/2022] [Accepted: 09/01/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Lung cancer is the leading cause of cancer mortality worldwide. Awareness interventions in the developing world remain scarce. Community health workers (CHWs) are a critical component towards ensuring efficient delivery of healthcare services in low- and middle-income countries. AIM This study explored the experiences of CHWs of their training as lung cancer awareness intervention implementers. SETTING The study was conducted in a resource-poor setting, with CHWs from previously disadvantaged communities. METHODS On the last day of training, 10 CHWs were requested to voluntarily participate in a focus group discussion regarding their experiences of the training, utilising a discussion guide. RESULTS The participants expressed positive experiences with the training. They cited the amenable and conducive learning environment established by the facilitator. The participants felt empowered through the newly acquired knowledge and wanted to help their communities. However, some participants expressed a desire to have other forms of learning incorporated in future training. The participants were also cognisant of existing gaps in their own knowledge that could be elaborated upon in preparation for potential questions by the community. Some participants confirmed their role as agents of change. CONCLUSION The authors propose large-scale intervention studies of lung cancer awareness utilising the CHW programme to gather conclusive evidence regarding their effectiveness at a community level.Contribution: This article provides insight into the training of community health workers on lung cancer awareness and future research on the integration of the intervention into already existing programmes.
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Affiliation(s)
- Siyabonga B. Dlamini
- Discipline of Public Health Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa,Cancer & Infectious Diseases Epidemiology Research Unit, College of Health Science, University of KwaZulu-Natal, Durban, South Africa
| | - Khumbulani W. Hlongwana
- Discipline of Public Health Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa,Cancer & Infectious Diseases Epidemiology Research Unit, College of Health Science, University of KwaZulu-Natal, Durban, South Africa
| | - Themba G. Ginindza
- Discipline of Public Health Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa,Cancer & Infectious Diseases Epidemiology Research Unit, College of Health Science, University of KwaZulu-Natal, Durban, South Africa
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Makabayi-Mugabe R, Musaazi J, Zawedde-Muyanja S, Kizito E, Namwanje H, Aleu P, Charlet D, Freitas Lopez DB, Brightman H, Turyahabwe S, Nkolo A. Developing a patient-centered community-based model for management of multi-drug resistant tuberculosis in Uganda: a discrete choice experiment. BMC Health Serv Res 2022; 22:154. [PMID: 35123467 PMCID: PMC8817775 DOI: 10.1186/s12913-021-07365-5] [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: 04/20/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The advent of all-oral regimens for the management of multi-drug resistant tuberculosis (MDR-TB) makes the implementation of community-based directly observed therapy (CB-DOT) a possibility for this group of patients. We set out to determine patient preferences for different attributes of a community-based model for the management of MDR-TB in Uganda.
Methods
The study was conducted at five tertiary referral hospitals. We used a parallel convergent mixed methods study design. To collect quantitative data, we conducted a discrete choice experiment (DCE) with three different attributes of community-based care (DOT provider, location of care, and type of support) combined into eight choice sets, each with two options and an opt-out. We elicited patient reasons for selection of each choice set using qualitative methods. We fitted a mixed logit choice model to determine patient preferences for different attributes of community-based care and estimated the relative importance of each attribute using the range method. and used deductive thematic analysis to understand the reasons for the choices made.
Results
From December 2019 to January 2020, we interviewed 103 patients with MDR-TB. We found that all the three attributes considered were important predicators of choice. The relative importance of each attribute was as follows; the type of additional support (relative importance 36.2%), the location of treatment delivery (33.5%), and the type of DOT provider (30.3%). Participants significantly valued treatment delivered by community health workers (CHWs) or expert clients over that delivered by a family member, treatment delivered at home over that delivered at the workplace, and monthly travel vouchers as the form of additional support over phone call or SMS reminders. Subgroup analyses showed significant differences in preference across HIV status, age groups and duration on MDR-TB treatment, but not across gender.
The preferred model consisted of a CHW giving DOT at home and travel vouchers to enable attendance of monthly clinic follow-up visits to tertiary referral hospitals for treatment monitoring. Qualitative interviews revealed that patients perceived CHWs as knowledgeable and able to offer psychosocial support. Patients also preferred to take medication at home to save both time and money and lower the risk of facing TB stigma.
Conclusion
People with MDR-TB prefer to be supported to take their medicine at home by a member of their community. The effectiveness of this model of care is being further evaluated.
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Peresu E, Heunis JC, Kigozi NG, De Graeve D. Task-shifting directly observed treatment and multidrug-resistant tuberculosis injection administration to lay health workers: stakeholder perceptions in rural Eswatini. HUMAN RESOURCES FOR HEALTH 2020; 18:97. [PMID: 33272307 PMCID: PMC7712623 DOI: 10.1186/s12960-020-00541-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 11/24/2020] [Indexed: 05/13/2023]
Abstract
BACKGROUND Eswatini is facing a critical shortage of human resources for health (HRH) and limited access to multidrug-resistant tuberculosis (MDR-TB) treatment in rural areas. This study assessed multiple stakeholders' perceptions of task-shifting directly observed treatment (DOT) supervision and administration of intramuscular MDR-TB injections to lay health workers (LHWs). METHODS A mixed methods study comprising a cross-sectional survey using a semi-structured questionnaire with community treatment supporters (CTSs) and a focus group discussion with key stakeholders including representatives from the Eswatini Ministry of Health (MOH), donor organisations, professional regulatory institutions, nursing academia, civil society and healthcare providers was conducted in May 2017. Descriptive statistics, thematic content analysis and data triangulation aided in the interpretation of results. RESULTS A large majority of CTSs (n = 78; 95.1%) were female and 33 (40.2%) were older than 50 years. Most (n = 7; 70.0%) key stakeholders had over 10 years of work experience in policy-making, advocacy in the fields of HRH or day-to-day practice in MDR-TB management. Task-shifting of MDR-TB injection administration was implemented without national policy guidance and regulation. Stakeholders viewed the strategy to be driven by the prevailing shortage of professional frontline HRH and limited access to MDR-TB treatment. Task-shifting was perceived to improve medication adherence, and reduce stigma and transport-related MDR-TB treatment access barriers. Frontline healthcare workers and implementing donor partners fully supported task-shifting. Policy-makers and other stakeholders accepted task-shifting conditionally due to fears of poor standards of care related to perceived incompetence of CTSs. Appropriate compensation, adequate training and supervision, and non-financial incentives were suggested to retain CTSs. A holistic task-shifting policy and collaboration between the MOH, academia and nursing council in regulating the practice were recommended. CONCLUSIONS Stakeholders generally accepted the delegation of DOT supervision and administration of intramuscular MDR-TB injections to LHWs as a strategy to increase access to treatment, albeit with some apprehension. Findings from this study stress that task-shifting is not a panacea for HRH shortages, but a short-term solution that must form part of an overall simultaneous strategy to train, attract and retain adequate numbers of professional healthcare workers in Eswatini. To address some of the apprehension and ambivalence about expanding access to MDR-TB services through task-shifting, attention should be paid to important aspects such as competence-based training, certification and accreditation, adequate supportive on-the-job supervision, recognition, compensation, and expediting policy and regulatory support for LHWs.
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Affiliation(s)
- Ernest Peresu
- Centre for Development Support, Faculty of Economic and Management Sciences, University of the Free State, P.O. Box 399, Bloemfontein, 9300, South Africa.
| | - J Christo Heunis
- Centre for Health Systems Research & Development, University of the Free State, P.O. Box 399, Bloemfontein, 9300, South Africa
| | - N Gladys Kigozi
- Centre for Health Systems Research & Development, University of the Free State, P.O. Box 399, Bloemfontein, 9300, South Africa
| | - Diana De Graeve
- Faculty of Business and Economics, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium
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Tahseen S, Van Deun A, de Jong BC, Decroo T. Second-line injectable drugs for rifampicin-resistant tuberculosis: better the devil we know? J Antimicrob Chemother 2020; 76:831-835. [DOI: 10.1093/jac/dkaa489] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
In its 2020 guidelines for the treatment of rifampicin-resistant TB (RR-TB), the WHO recommends all-oral fluoroquinolone-based regimens, with bedaquiline replacing the second-line injectable drugs (SLIDs). SLIDs were used for their strong acquired resistance-preventing activity. Data from three cohorts showed acquired bedaquiline resistance ranging between 2.5% and 30.8%, with no protection from a SLID in most cases. If bedaquiline resistance is that easily acquired, it will fail to protect fluoroquinolones and other drugs from acquiring resistance. Until evidence on resistance-preventing activity shows that SLIDs can safely be replaced, we call for more prudent use of the few potent second-line TB drugs available. Studies on new treatment regimens need to prioritize the prevention of acquired resistance along with treatment success. Meanwhile, reducing the dosing of SLIDs to thrice weekly from Day 1, and their replacement for any degree of audiometry abnormalities before or during treatment will largely avoid serious ototoxicity.
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Affiliation(s)
- Sabira Tahseen
- National TB Reference laboratory, National TB Control Program, Islamabad, Pakistan
| | | | - Bouke C de Jong
- Institute of Tropical Medicine, Unit of Mycobacteriology, Department of Biomedical Sciences, 2000, Antwerp, Belgium
| | - Tom Decroo
- Institute of Tropical Medicine, Unit of HIV and TB, Department of Clinical Sciences, 2000, Antwerp, Belgium
- Research Foundation Flanders, 1000 Brussels, Belgium
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