Identifying contextual determinants of problems in tuberculosis care provision in South Africa: a theory-generating case study

Jamie Murdoch,Lara Fairall,Max Bachmann,Inge Petersen,Robyn Curran,Audry Dube,André J Van Rensburg,Ajibola Awotiwon

doi:10.1186/s40249-021-00840-5

Abstract

BackgroundDespite progress towards End TB Strategy targets for reducing tuberculosis (TB) incidence and deaths by 2035, South Africa remains among the top ten high-burden tuberculosis countries globally. A large challenge lies in how policies to improve detection, diagnosis and treatment completion interact with social and structural drivers of TB. Detailed understanding and theoretical development of the contextual determinants of problems in TB care is required for developing effective interventions. This article reports findings from the pre-implementation phase of a study of TB care in South Africa, contributing to HeAlth System StrEngThening in Sub-Saharan Africa (ASSET)—a five-year research programme developing and evaluating health system strengthening interventions in sub-Saharan Africa. The study aimed to develop hypothetical propositions regarding contextual determinants of problems in TB care to inform intervention development to reduce TB deaths and incidence whilst ensuring the delivery of quality integrated, person-centred care.MethodsTheory-building case study design using the Context and Implementation of Complex Interventions (CICI) framework to identify contextual determinants of problems in TB care. Between February and November 2019, we used mixed methods in six public-sector primary healthcare facilities and one public-sector hospital serving impoverished urban and rural communities in the Amajuba District of KwaZulu-Natal Province, South Africa. Qualitative data included stakeholder interviews, observations and documentary analysis. Quantitative data included routine data on sputum testing and TB deaths. Data were inductively analysed and mapped onto the seven CICI contextual domains.ResultsDelayed diagnosis was caused by interactions between fragmented healthcare provision; limited resources; verticalised care; poor TB screening, sputum collection and record-keeping. One nurse responsible for TB care, with limited integration of TB with other conditions, and policy focused on treatment adherence contributed to staff stress and limited consideration of patients’ psychosocial needs. Patients were lost to follow up due to discontinuity of information, poverty, employment restrictions and limited support for treatment side-effects. Infection control measures appeared to be compromised by efforts to integrate care.ConclusionsDelayed diagnosis, limited psychosocial support for patients and staff, patients lost to follow-up and inadequate infection control are caused by an interaction between multiple interacting contextual determinants. TB policy needs to resolve tensions between treating TB as epidemic and individually-experienced social problem, supporting interventions which strengthen case detection, infection control and treatment, and also promote person-centred support for healthcare professionals and patients.Graphic abstract

Highlights

Despite progress towards End TB Strategy targets for reducing tuberculosis (TB) incidence and deaths by 2035, South Africa remains among the top ten high-burden tuberculosis countries globally
Contextual determinants of problems in TB care interacted across macro, meso- and micro-contextual levels contributing to delayed TB diagnosis, limited support for staff and patients’ psychosocial needs, patients lost to follow-up after diagnosis, and inadequate infection control within primary healthcare (PHC) facilities (Additional file 4)
Ideal Clinic policy requires that nurses screen patients for TB in vital signs rooms, asking four questions: ‘Do you have a cough?’; ‘Do you have a fever?’; ‘Have you lost weight?’; and ‘Are you sweating a lot at night?’ we observed wide variation in TB screening practices, taking place within and outside vital signs rooms and inconsistent questioning of patients, sometimes only occurring if patients showed signs or symptoms

Summary

Introduction

Despite progress towards End TB Strategy targets for reducing tuberculosis (TB) incidence and deaths by 2035, South Africa remains among the top ten high-burden tuberculosis countries globally. While South Africa, long a high-burden TB country, has made important strides in this direction, the country’s TB epidemic continues to impose a substantial burden on its health system and people—South Africa’s 2019 TB incidence rate of 615 per 100 000 population is exceptionally high compared against the global average of 130 per 100 000 [1]; there is a 58% undetected TB burden in the community [3]; and in 2017 TB was the leading cause of death overall, contributing 6% of all deaths [4]. These figures are especially troubling given that approximately 160 000 people with known active TB are lost to follow-up [4]

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