Barriers and facilitators to accessing tuberculosis care in Nepal: a qualitative study to inform the design of a socioeconomic support intervention

Abstract

ObjectivePsychosocial and economic (socioeconomic) barriers, including poverty, stigma and catastrophic costs, impede access to tuberculosis (TB) services in low-income countries. We aimed to characterise the socioeconomic barriers and facilitators of accessing TB services in Nepal to inform the design of a locally appropriate socioeconomic support intervention for TB-affected households.DesignFrom August 2018 to July 2019, we conducted an exploratory qualitative study consisting of semistructured focus group discussions (FGDs) with purposively selected multisectoral stakeholders. The data were managed in NVivo V.12, coded by consensus and analysed thematically.SettingThe study was conducted in four districts, Makwanpur, Chitwan, Dhanusha and Mahottari, which have a high prevalence of poverty and TB.ParticipantsSeven FGDs were conducted with 54 in-country stakeholders, grouped by stakeholders, including people with TB (n=21), community stakeholders (n=13) and multidisciplinary TB healthcare professionals (n=20) from the National TB Programme.ResultsThe perceived socioeconomic barriers to accessing TB services were: inadequate TB knowledge and advocacy; high food and transportation costs; income loss and stigma. The perceived facilitators to accessing TB care and services were: enhanced championing and awareness-raising about TB and TB services; social protection including health insurance; cash, vouchers and/or nutritional allowance to cover food and travel costs; and psychosocial support and counselling integrated with existing adherence counselling from the National TB Programme.ConclusionThese results suggest that support interventions that integrate TB education, psychosocial counselling and expand on existing cash transfer schemes would be locally appropriate and could address the socioeconomic barriers to accessing and engaging with TB services faced by TB-affected households in Nepal. The findings have been used to inform the design of a socioeconomic support intervention for TB-affected households. The acceptability, feasibility and impact of this intervention on TB-related costs, stigma and TB treatment outcomes, is now being evaluated in a pilot implementation study in Nepal.

Health-related quality of life of persons living with tuberculosis: A cross-sectional study

“…Thus, to ensure social protection for persons living with TB, the list of health services covered by the national health insurance scheme should be expanded to cover more TB-related health services. Furthermore, patients receiving treatment for TB could be provided regular allowances to cover their indirect and non-medical costs such as transportation and food-related expenses [9] , [19] .…”

“…Thus, treatment for TB may have to consider regular assessment and management of psychological issues related to the meaningfulness of patients’ lives as well as negative feelings such as anxiety or depression [10] . The psychosocial concerns of persons living with TB can also be addressed through counselling services and linkages of the vulnerable to welfare schemes that would provide them with financial protection and social security measures in Ghana [9] . Furthermore, healthcare providers and health facility managers could consider implementing measures which promote the acceptability and effectiveness of comprehensive psychosocial services in addition to the medical services for the persons living with TB [16] , [24] .…”

Investigating factors influencing implementation of tuberculosis infection prevention and control in rural Papua New Guinea

“…To improve research validity and reliability, the data collection drew on three primary sources to triangulate data: semistructured interviews, document reviews, and eld notes captured throughout the study. 29 For each case, semi-structured interviews were audio-recorded with purposefully selected stakeholders with diverse perspectives to gather their views on the barriers and strategies of TB-IPC measures. Health services documents, including strategic plans, operational plans, health promotion posters, and health services reports were reviewed to generate a clear understanding of the policies and policy environment related to TB-IPC policy.…”

Protocol for the Addressing the Social Determinants and Consequences of Tuberculosis in Nepal (ASCOT) pilot trial

“…Mental health including depression measured by an adapted PHQ9 previously validated in Nepal, a resilience scale, and the EuroHIS-QoL 12 , 17 , 40 ;…”

“… Legend: The inner white circle contains the key categories that influence TB service access and engagement, which are adapted from a World Health Organization Medication Adherence Framework 17 . The middle red circle indicates the main barriers identified for each category, which may threaten access to TB services.…”