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Nunemo MH, Gidebo KD, Woticha EW, Lemu YK. Integration Challenges and Opportunity of Implementing Non-Communicable Disease Screening Intervention with Tuberculosis Patient Care: A Mixed Implementation Study. Risk Manag Healthc Policy 2023; 16:2609-2633. [PMID: 38045564 PMCID: PMC10693204 DOI: 10.2147/rmhp.s432943] [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: 08/25/2023] [Accepted: 11/18/2023] [Indexed: 12/05/2023] Open
Abstract
Background Despite the comorbidity, early detection and treatment of the two diseases are highly recommended; however, a few pilot studies were conducted, which are mainly focused on diabetes mellitus screening and the integration opportunity and challenges were not known. The study aimed to identify integrated implementation challenges and opportunities of non-communicable disease and risk factors screening intervention with tuberculosis patient care. Methods A mixed implementation study design was used. Data were collected from a sample of 443 tuberculosis patients, 21 key informants and facility observations. For quantitative data, descriptive statistics for proportion were summarized in tables and figures. Four distinct implementation frame was adapted for thematic analysis of audio recordings, daily verbatim transcription, and descriptive field notes. Results The prevalence of hypertension and diabetes mellitus among tuberculosis patients were 6.55% and 5.64%, respectively. Totally 9 subthemes and 21 new codes were developed, of which 13 and 8 new codes were developed for integrated implementation challenges and opportunities, respectively. The absence of medical equipment, skill and knowledge training, record and report system, cooperative integration, feedback, referral system, shortage of supporting agencies, and services not free were external challenges, whereas lack of trained health workers, focal persons, and increased workload and absence of awareness creation were internal challenges. Despite the challenges, the presence of health extension programs, non-governmental organizations, community health care insurance and associations for diabetes mellitus were external opportunities. Availability of assigned focal persons, trained stakeholders, guidelines, information systems and compatible tuberculosis program structure were internal opportunities. Conclusion The majority of TB patients were not comorbid with NCDs. We build a favourable system for integrated implementation developing an integration platform and structural authority at a different organization by addressing identified challenges and applying facilitators is crucial.
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Affiliation(s)
| | - Kassa Daka Gidebo
- Department of Public Health, Wolaita Sodo University, Wolaita, South Region, Ethiopia
| | | | - Yohannes Kebede Lemu
- Department of Health, Behaviour and Society, Jimma University, Jimma, Oromia Region, Ethiopia
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Asemahagn MA. Missed Tuberculosis Investigations and Associated Factors in Patients with Symptoms Indicative of Tuberculosis at Public Health Institutions in Northwest Ethiopia: The Application of a Negative Binomial Model. Infect Drug Resist 2022; 15:1947-1956. [PMID: 35469307 PMCID: PMC9034845 DOI: 10.2147/idr.s355247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 03/26/2022] [Indexed: 11/23/2022] Open
Abstract
Background Tuberculosis (TB) remains one of the top health problems in Ethiopia, and over one-third of estimated TB cases remain undetected. This study examined the magnitude and factors of missed opportunities for TB investigation at public health facilities in Northwest Ethiopia. Methods A facility-based cross-sectional study was conducted among 412 adult patients with TB symptoms from 34 randomly selected public health facilities. Data on socio-demographics, TB symptoms, and clinical status were collected by an exit interview. A patient was considered missed for TB investigation if he/she had at least one symptom suggestive of TB but did not receive a sputum smear and/or x-ray evaluation to rule out TB. We computed descriptive and analytical statistics using SPSS version 26. A negative binomial regression analysis was used to identify factors associated with missed opportunities for TB investigation. Statistical significance was determined at a p-value less than 0.05. Results A total of 412 presumptive TB patients, 235 (57%) females and 247 (60%) rural dwellers were interviewed. The mean age of respondents was 35 ± 8 years and 228 (55.3%) were from health centers. Over two-thirds, 284 (69%) were new patients, 62 (15%) were HIV positive and 78 (19%) had diabetes mellitus (DM). Fifty patients with symptoms suggestive of TB did not receive sputum evaluation services. Inability to read and write, having DM, having normal body mass index and facility type they visited were significant factors to missing opportunities to get TB investigations. Conclusion A significant number of patients with symptoms suggestive of TB were missed for sputum evaluation to rule out TB. Education level, comorbidity, nutritional status and type of facility patients attended were factors of missing opportunities for TB investigation. Thus, improving quality of TB diagnosis, screening TB among all types of patients, and paying attention to screen illiterate people are crucial to avoid missing potential TB cases.
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Affiliation(s)
- Mulusew Andualem Asemahagn
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
- Correspondence: Mulusew Andualem Asemahagn, Email
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Der JB, Grint DJ, Narh CT, Bonsu F, Grant AD. Missed opportunities for tuberculosis investigation in a municipal hospital in Ghana: evidence from patient exit interviews. Trans R Soc Trop Med Hyg 2021; 115:43-50. [PMID: 32838415 DOI: 10.1093/trstmh/traa080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/23/2020] [Accepted: 08/05/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We assessed coverage of symptom screening and sputum testing for tuberculosis (TB) in hospital outpatient clinics in Ghana. METHODS In a cross-sectional study, we enrolled adults (≥18 years) exiting the clinics reporting ≥1 TB symptom (cough, fever, night sweats or weight loss). Participants reporting a cough ≥2 weeks or a cough of any duration plus ≥2 other TB symptoms (per national criteria) and those self-reporting HIV-positive status were asked to give sputum for testing with Xpert MTB/RIF. RESULTS We enrolled 581 participants (median age 33 years [IQR: 24-48], 510/581 [87.8%] female). The most common symptoms were fever (348, 59.9%), chest pain (282, 48.5%) and cough (270, 46.5%). 386/581 participants (66.4%) reported symptoms to a healthcare worker, of which 157/386 (40.7%) were eligible for a sputum test per national criteria. Only 31/157 (19.7%) had a sputum test requested. Thirty-two additional participants gave sputum among 41 eligible based on positive HIV status. In multivariable analysis, symptom duration ≥2 weeks (adjusted odds ratio [aOR] 6.99, 95% confidence interval [CI] 2.08-23.51) and previous TB treatment (aOR: 6.25, 95% CI: 2.24-17.48) were the strongest predictors of having a sputum test requested. 6/189 (3.2%) sputum samples had a positive Xpert MTB/RIF result. CONCLUSION Opportunities for early identification of people with TB are being missed in health facilities in Ghana.
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Affiliation(s)
- Joyce B Der
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Daniel J Grint
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Clement T Narh
- School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana.,Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Frank Bonsu
- National TB Control Program, Disease Control and Prevention Department, Ghana Health Service, Accra, Ghana
| | - Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,Africa Health Research Institute, School of Laboratory Medicine & Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Oga-Omenka C, Bada F, Agbaje A, Dakum P, Menzies D, Zarowsky C. Ease and equity of access to free DR-TB services in Nigeria- a qualitative analysis of policies, structures and processes. Int J Equity Health 2020; 19:221. [PMID: 33302956 PMCID: PMC7731779 DOI: 10.1186/s12939-020-01342-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/01/2020] [Indexed: 12/04/2022] Open
Abstract
Introduction Persistent low rates of case notification and treatment coverage reflect that accessing diagnosis and treatment for drug-resistant tuberculosis (DR-TB) in Nigeria remains a challenge, even though it is provided free of charge to patients. Equity in health access requires availability of comparable, appropriate services to all, based on needs, and irrespective of socio-demographic characteristics. Our study aimed to identify the reasons for Nigeria’s low rates of case-finding and treatment for DR-TB. To achieve this, we analyzed elements that facilitate or hinder equitable access for different groups of patients within the current health system to support DR-TB management in Nigeria. Methods We conducted documentary review of guidelines and workers manuals, as well as 57 qualitative interviews, including 10 focus group discussions, with a total of 127 participants, in Nigeria. Between August and November 2017, we interviewed patients who were on treatment, their treatment supporter, and providers in Ogun and Plateau States, as well as program managers in Benue and Abuja. We adapted and used Levesque’s patient-centered access to care framework to analyze DR-TB policy documents and interview data. Results Thematic analysis revealed inequitable access to DR-TB care for some patient socio-demographic groups. While patients were mostly treated equally at the facility level, some patients experienced more difficulty accessing care based on their gender, age, occupation, educational level and religion. Health system factors including positive provider attitudes and financial support provided to the patients facilitated equity and ease of access. However, limited coverage and the absence of patients’ access rights protection and considerations in the treatment guidelines and workers manuals likely hampered access. Conclusion In the context of Nigeria’s low case-finding and treatment coverage, applying an equity of access framework was necessary to highlight gaps in care. Differing social contexts of patients adversely affected their access to DR-TB care. We identified several strengths in DR-TB care delivery, including the current financial support that should be sustained. Our findings highlight the need for government’s commitment and continued interventions.
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Affiliation(s)
- Charity Oga-Omenka
- The School of Public Health of the University of Montreal (ÉSPUM), 7101, Parc avenue, 3rd floor, Montreal, Quebec, H3N 1X9, Canada. .,Centre de recherche en santé publique, Université de Montréal (CReSP), Montreal, Canada. .,McGill University International TB Centre, Montreal, Quebec, Canada.
| | - Florence Bada
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Aderonke Agbaje
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Patrick Dakum
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Dick Menzies
- McGill University International TB Centre, Montreal, Quebec, Canada.,Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
| | - Christina Zarowsky
- The School of Public Health of the University of Montreal (ÉSPUM), 7101, Parc avenue, 3rd floor, Montreal, Quebec, H3N 1X9, Canada.,Centre de recherche en santé publique, Université de Montréal (CReSP), Montreal, Canada.,School of Public Health, University of the Western Cape, Cape Town, South Africa
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Oga-Omenka C, Tseja-Akinrin A, Sen P, Mac-Seing M, Agbaje A, Menzies D, Zarowsky C. Factors influencing diagnosis and treatment initiation for multidrug-resistant/rifampicin-resistant tuberculosis in six sub-Saharan African countries: a mixed-methods systematic review. BMJ Glob Health 2020; 5:e002280. [PMID: 32616481 PMCID: PMC7333807 DOI: 10.1136/bmjgh-2019-002280] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/10/2020] [Accepted: 04/15/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Drug-resistant tuberculosis burdens fragile health systems in sub-Saharan Africa (SSA), complicated by high prevalence of HIV. Several African countries reported large gaps between estimated incidence and diagnosed or treated cases. Our review aimed to identify barriers and facilitators influencing diagnosis and treatment for drug-resistant tuberculosis (DR-TB) in SSA, which is necessary to develop effective strategies to find the missing incident cases and improve quality of care. METHODS Using an integrative design, we reviewed and narratively synthesised qualitative, quantitative and mixed-methods studies from nine electronic databases: Medline, Global Health, CINAHL, EMBASE, Scopus, Web of Science, International Journal of Tuberculosis and Lung Disease, PubMed and Google Scholar (January 2006 to June 2019). RESULTS Of 3181 original studies identified, 55 full texts were screened, and 29 retained. The studies included were from 6 countries, mostly South Africa. Barriers and facilitators to DR-TB care were identified at the health system and patient levels. Predominant health system barriers were laboratory operational issues, provider knowledge and attitudes and information management. Facilitators included GeneXpert MTB/RIF (Xpert) diagnosis and decentralisation of services. At the patient level, predominant barriers were patients being lost to follow-up or dying due to lengthy diagnostic and treatment delays, negative public sector care perceptions, family, work or school commitments and using private sector care. Some patient-level facilitators were HIV positivity and having more symptoms. CONCLUSION Case detection and treatment for DR -TB in SSA currently relies on individual patients presenting voluntarily to the hospital for care. Specific interventions targeting identified barriers may improve rates and timeliness of detection and treatment.
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Affiliation(s)
- Charity Oga-Omenka
- École de santé publique de l'Université de Montréal (ESPUM), Montréal, Quebec, Canada
- Centre de recherche en santé publique, Université de Montréal (CReSP), Montréal, Quebec, Canada
- McGill International TB Centre, Montreal, Quebec, Canada
| | | | - Paulami Sen
- McGill International TB Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Muriel Mac-Seing
- École de santé publique de l'Université de Montréal (ESPUM), Montréal, Quebec, Canada
- Centre de recherche en santé publique, Université de Montréal (CReSP), Montréal, Quebec, Canada
| | | | - Dick Menzies
- McGill International TB Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Christina Zarowsky
- École de santé publique de l'Université de Montréal (ESPUM), Montréal, Quebec, Canada
- Centre de recherche en santé publique, Université de Montréal (CReSP), Montréal, Quebec, Canada
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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