Tuberculosis Service Delivery Research Articles

Action towards Universal Health Coverage and Social Protection for Tuberculosis Care and Prevention: Workshop on the End TB Strategy Pillar 2 in the Western Pacific Region 2017.

Although the End TB Strategy highlights that major global progress towards universal health coverage (UHC) and social protection are fundamental to achieving the global targets for reductions in tuberculosis (TB) incidence and deaths, there is still a long way to go to achieve them in low- and middle-income countries. A workshop on the End TB Strategy Pillar 2 in the Western Pacific Region focusing on action towards UHC and social protection was held between 27 and 29 November in 2017 at the Korean Institute of Tuberculosis in Cheonju, Republic of Korea. The workshop brought together key personnel from national TB programmes and other stakeholders or researchers with experience in this topic from six countries with a high burden of TB in the region. During the workshop, participants shared country experiences, best practices, and challenges in achieving UHC and enhancing social protection in the context of TB service delivery, and also explored policy options to address the challenges, to be applied in their respective countries. This report describes the content of the meeting and the conclusions and recommendations arising from the meeting.

What can National TB Control Programmes in low- and middle-income countries do to end tuberculosis by 2030?

The international community has committed to ending the tuberculosis (TB) epidemic by 2030. This will require multi-sectoral action with a focus on accelerating socio-economic development, developing and implementing new tools, and expanding health insurance coverage. Within this broad framework, National TB Programmes (NTPs) are accountable for delivering diagnostic, treatment, and preventive services. There are large gaps in the delivery of these services, and the aim of this article is to review the crucial activities and interventions that NTPs must implement in order to meet global targets and milestones that will end the TB epidemic. The key deliverables are the following: turn End TB targets and milestones into national measurable indicators to make it easier to track progress; optimize the prompt and accurate diagnosis of all types of TB; provide rapid, complete, and effective treatment to all those diagnosed with TB; implement and monitor effective infection control practices; diagnose and treat drug-resistant TB, associated HIV infection, and diabetes mellitus; design and implement active case finding strategies for high-risk groups and link them to the treatment of latent TB infection; engage with the private-for-profit sector; and empower the Central Unit of the NTP particularly in relation to data-driven supportive supervision, operational research, and sustained financing. The glaring gaps in the delivery of TB services must be remedied, and some of these gaps will require new paradigms and ways of working which include patient-centered and higher-quality services. There must also be fast-track ways of incorporating new diagnostic, treatment, and prevention tools into program activities so as to rapidly reduce TB incidence and mortality and meet the goal of ending TB by 2030.

Delivering Patient-Centered Care in a Fragile State: Using Patient-Pathway Analysis to Understand Tuberculosis-Related Care Seeking in Pakistan.

BackgroundPakistan has the sixth largest population in the world and boasts the fifth greatest burden of tuberculosis. The Government of Pakistan has set the ambitious goal of zero deaths due to tuberculosis and universal access to tuberculosis care by 2020. Successfully reaching these goals is dependent on the country’s capacity to diagnose and successfully treat an estimated 200000 unnotified or missing patients with tuberculosis.MethodsA patient-pathway analysis (PPA) was conducted at the national level, as well as for each of the 4 provinces, to assess the alignment between patient care seeking and the availability of tuberculosis diagnostic and treatment services.ResultsAlmost 90% of patients initiated care in the private sector, which accounts for only 15% of facilities with the capacity for tuberculosis diagnosis and treatment. Across the country, nearly 50% of tuberculosis microscopy laboratories were located in public-sector–basic health units and regional health centers. However, very few patients initiated care in these facilities. Overall, tuberculosis case detection was high given the low likelihood of patients reaching facilities with the capacity for tuberculosis service delivery during their first visit.DiscussionImproving the engagement of the informal sector and lower-level clinicians will improve the efficiency and timeliness of tuberculosis diagnosis for patients in Pakistan. Concurrently, the apparent strength of the referral networks connecting community-level workers and private clinicians to the public sector for tuberculosis diagnosis and treatment suggests that strengthening the capacity of the public sector could be valuable.

The influence of integrated tuberculosis and human immunodeficiency virus service delivery on patient outcomes

Public health clinics in Cape Town, South Africa. To examine the influence of integrated tuberculosis (TB) and human immunodeficiency virus (HIV) service delivery on mortality, TB cure and successful treatment completion and loss to follow-up of TB-HIV co-infected patients on concurrent anti-tuberculosis and antiretroviral treatment (ART). A survey instrument was used to measure the degree to which TB and HIV services were jointly delivered, and patient data were collected retrospectively from clinic sites and the Department of Health. Six domains measuring integrated TB and HIV service delivery were modelled to assess their relationship with patient outcomes. Two domains, integrated TB and ART service delivery and the delivery of TB and HIV care by one clinical team, were associated with lowered odds of death. Care by the same clinical team was also associated with reduced loss to follow-up. Overall, these findings show that the organization and delivery of health services are important factors that influence health outcomes. These findings strongly support efforts by local governments to integrate TB and ART services, and may help to alleviate concerns that restructuring of TB programs could have a negative impact on long-standing gains.

An exploration of NHS staff views on tuberculosis service delivery in Scottish NHS boards.

Tuberculosis (TB) is a bacterial disease and major worldwide killer with an increased UK incidence rate. This study aimed to explore the views of National Health Service (NHS) staff on TB service delivery models of care in NHS boards across Scotland. Eighteen semi-structured interviews were conducted with 13 nurse specialists and five consultants in public health medicine (CPHM) across five Scottish NHS boards. Five main themes emerged and findings showed that: directly observed treatment (DOT) was provided only to patients assessed to be at high risk of poor treatment adherence; contact tracing was conducted by participating NHS boards but screening at ports was thought to be weak; all NHS boards implemented TB awareness campaigns for TB health professionals; three NHS boards conducted team meetings that monitored TB patient progress; participants believed that TB funding should be increased; contact tracing was routinely conducted by TB nurses. Improved TB screening at airports was recommended and a need for TB health education for high risk groups was identified.

Listening to those on the frontline: service users' experiences of London tuberculosis services

Aim:To explore tuberculosis (TB) service users’ experiences and satisfaction with care provision.Background:Thirty-nine percent of all new UK TB cases occur in London. Prevalence varies considerably between and within boroughs. Overall, research suggests inadequate control of London’s TB transmission; TB has become a health care priority for all London Primary Care Trusts. Service users’ experiences and satisfaction with care provision have not been explored adequately previously.Methods:A qualitative research design, using semi-structured face-to-face interviews was used. Ten service users, purposively selected in key risk groups across London, were interviewed. All interviews were digitally recorded with users’ permission, transcribed verbatim, and analyzed thematically.Results:Participants were treated in local hospitals for 6–12 months. Treatment was administered by TB nurses to inpatients and outpatients receiving directly observed therapy in consultation with medical staff and home visits for complex cases. Two participants did not realize the importance of compliance. Overall, they were satisfied with many TB services’ aspects, communication, and service organization. Early access, low suspicion index amongst some GPs, and restricted referral routes were identified as service barriers. Other improvement areas were information provision on drug side effects, diet, nutritional status, and a few health professionals’ attitudes. The effects on people varied enormously from minimal impact to psychological shock; TB also affected social and personal aspects of their life. With regard to further support facilities, some positive views on managed accommodation by TB-aware professionals for those with accommodation problems were identified.Conclusion:This first in-depth study of TB service users’ experiences across London offers valuable insights into service users’ experiences, providing information and recommendations for a strategic framework for TB service organization and delivery. Overall, further research is needed; TB services – local, national, and international – need to be more closely aligned with service users’ complex needs.

Integration of Tuberculosis and HIV Services in Sub‐Saharan Africa: Lessons Learned

Promoting linkages between tuberculosis (TB) and human immunodeficiency virus (HIV) treatment and prevention programs in resource-constrained environments where both diseases are prevalent is essential to improve the diagnosis, treatment, and outcomes for patients affected by both diseases. In this article, we share insights based on our experiences supporting integrated TB and HIV service delivery programs, including intensified TB case finding, isoniazid preventive therapy, infection control, and initiation of antiretroviral therapy. Our experience indicates that successful integration of TB and HIV services in resource-constrained environments is feasible, although programmatic, infrastructural, and staffing challenges remain. Successful implementation of TB and HIV collaborative activities requires consideration of the realities that exist on the ground and the importance of tailoring interventions in a manner that enables their seamless introduction into existing programs that are often overwhelmed with large numbers of patients and a paucity of human and other resources.

Quality of tuberculosis care and its association with patient adherence to treatment in eight Ethiopian districts

Little is known about the quality of tuberculosis (TB) service delivery in public health facilities in Ethiopia and its association with patients' non-adherence to TB treatment. This study assessed the organization, management and processes of TB care delivery, and their effects on patients' adherence to TB treatment. The quality of TB care was investigated in 44 public health facilities from three perspectives: structure, processes of TB care delivery and patient treatment outcome. Quality of care was determined by adherence to national TB guidelines. On-site observations of TB service delivery and interviews with health providers were conducted to evaluate structural factors. Patients (n = 237) in the health facilities were interviewed prospectively at completion of their treatment to determine the quality of tuberculosis care delivered. Three measures of treatment adherence [treatment interruption (>or=2 weeks), availability of unused TB drugs and treatment default] were quantified from a review of patient treatment registers and an audit of unused TB drugs at patients' homes. Effects were identified of poor quality structures and processes of service delivery on these three measures of adherence. TB care providers were untrained in 18 (44%) of 44 facilities and daily outpatient TB care was not given in 13 of 44 (25%). Among the 237 patients, 43% interrupted treatment for >or=15 days and 30% had at least 1 day's dose of TB drugs unused. Patients tended to interrupt and default from treatment when their care provider had been inadequately supervised by district TB control experts and was incapable of dealing with patients' minor illnesses. Unavailability of daily TB care in health facilities was associated with missing daily doses. Better training of TB care providers and district supervisory support could be important interventions to improve the quality of care delivery and patient adherence to treatment.

Where do tuberculosis patients go for treatment before reporting to DOTS clinics in southern Nigeria

Health-seeking patterns of persons with tuberculosis (TB) before reporting at the Directly Observed Treatment Short-course (DOTS) clinic for diagnosis and treatment were analysed. A total of 221 persons registered in the DOTS programme in 12 randomly selected rural and urban Local Government Areas in southern Nigeria were interviewed using a semi-structured questionnaire. Perceived causes of TB influenced first choice of treatment. Patients re-evaluated initial choices and shop for alternatives in persistent TB. Chemists were the first port of call for most patients. Those with unscientific causative theories of tuberculosis such as witchcraft engaged more in multiple health-seeking than those who indicated bacterial infection (P < 0.0001). The respondents had a median diagnostic-delay of 90 days. Delay in commencement of DOTS treatment was attributable to ignorance among patients and poor attitude of health workers. In conclusion, delay exists between recognition of symptoms and initiation of treatment in DOTS clinics partly because of ignorance among patients. Health workers' attitude to patients reporting at health clinics also discouraged the use of DOTS facilities. Consequently, it is recommended to address such delay through social mobilization of communities and through engaging Chemists in TB service delivery in this area.

Cost-Effective Control of Drug-Resistant TB: Listening to Other Voices

Drug-resistant tuberculosis is mainly a phenomenon caused by physicians patients and health-care systems through incorrect treatments noncompliance and poor delivery of tuberculosis services respectively. These man-made facts could be avoided with appropriate actions. However the weakness of health systems in the tuberculosis high-burden countries hampers successful control. Public health priorities in resource-poor settings have marginalized tuberculosis cases resistant to first-line treatment. Nevertheless patients have been claiming their rights to be treated despite their drug resistance pattern. Nowadays tuberculosis programs try to address drug resistance issues. However pilot experiences in low-resource settings do not fully answer to the real challenges in the field to scale up second-line drug treatments. (excerpt)