Abstract
BackgroundThere is a need for innovative strategies to improve TB testing uptake and patient retention along the continuum of TB care early-on in treatment without burdening under-resourced health systems. We used a mixed methods approach to develop and pilot test a tuberculosis literacy and counselling intervention at an urban clinic in KwaZulu Natal, South Africa, to improve TB testing uptake and retention in tuberculosis care.MethodsWe engaged in discussions with clinic staff to plan and develop the intervention, which was delivered by senior social work students who received one-week training. The intervention included: 1) group health talks with all patients attending the primary clinic; and 2) individual counselling sessions, using motivational interviewing techniques, with newly diagnosed tuberculosis patients. We compared social work students’ tuberculosis knowledge, attitudes, and practices before and after their training. We assessed the change in number of tuberculosis diagnostic tests performed after implementation via an interrupted time series analysis with a quasi-Poisson regression model. We compared pre- and post-intervention probabilities of treatment initiation and completion using regression analyses, adjusting for potential baseline confounders. We conducted focus groups with the students, as well as brief surveys and one-on-one interviews with patients, to assess acceptability, feasibility, and implementation.ResultsDuring the study period, 1226 individuals received tuberculosis diagnostic testing and 163 patients started tuberculosis treatment, of whom 84 (51.5%) received individual counselling. The number of diagnostic tuberculosis tests performed increased by 1.36 (95%CI 1.23–1.58) times post-intervention, adjusting for background calendar trend. Probabilities of TB treatment initiation and treatment completion increased by 10.1% (95%CI 1.5–21.3%) and 4.4% (95%CI -7.3-16.0%), respectively. Patients found the counselling sessions alleviated anxiety and increased treatment self-efficacy. Social work students felt the clinic staff were collaborative and highly supportive of the intervention, and that it improved patient engagement and adherence.ConclusionsEngaging clinic staff in the development of an intervention ensures buy-in and collaboration. Education and counselling before and early-on in tuberculosis treatment can increase tuberculosis testing and treatment uptake. Training junior social workers can enable task-shifting in under-resourced settings, while addressing important service gaps in tuberculosis care.
Highlights
There is a need for innovative strategies to improve TB testing uptake and patient retention along the continuum of TB care early-on in treatment without burdening under-resourced health systems
Training junior social workers can enable task-shifting in under-resourced settings, while addressing important service gaps in tuberculosis care
TB literacy and treatment counselling intervention We developed an intervention framework that drew on components from other published TB counselling programs (e.g. [17,18,19,20,21]) and from the strengths-based approach, a social work practice theory that focuses on individuals’ strengths and resources in order to create opportunities and achieve their goals [22]; it is a clientcentred, empowerment-based practice that promotes self-competence rather than the stigmatising notion of deficit
Summary
There is a need for innovative strategies to improve TB testing uptake and patient retention along the continuum of TB care early-on in treatment without burdening under-resourced health systems. The main global approach to promote TB treatment adherence and retention is directly observed therapy (DOT), wherein a designated supervisor such as a health provider or community member observes patients ingest their medicines This approach imposes a heavy demand on already fragile health resources and is inconsistently implemented in many parts of South Africa; patients are formally observed only once per week or month, if at all, with little to no support during the interim periods. Innovative strategies that engage patients early on to prevent pre-treatment losses to follow-up, as well as during TB care to resolve unaddressed barriers to adherence, without burdening under-resourced health systems, are urgently needed [8, 9]
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