Explaining the successes and failures of tuberculosis treatment programs; a tale of two regions in rural Eastern Uganda

Izudi, Jonathan; Tamwesigire, Imelda K.; Bajunirwe, Francis

doi:10.21203/rs.2.15576/v1

Cited by 3 publications

(5 citation statements)

References 10 publications

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“…The increased workload was mostly attributed to a lack of human resources in the facility as staff recommended that increased human resources could offset the strained workload. Shea et al's study findings were consistent with our findings and similarly recommended for the recruitment of more staff plus provision of additional support to improve readiness levels [28]. Another identified challenge was that staff may not have devoted time for the program within their overwhelmed schedule which might impede implementation.…”

Section: Task Demandssupporting

confidence: 88%

“…nurses, charge nurses, administrators and medical directors) [21, 28]. Therefore for future work, it is worthy to note that some questions in readiness tools may have more of a clinical meaning for participants, for example in our study that were majorly nurses as compared to other studies that had mostly leaders who may have more of an administrative meaning [28].…”

Section: Discussionmentioning

confidence: 92%

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Organizational Readiness for the Implementation of a Three-Month Short-Course TB Preventive Therapy Regimen (3HP) in Four Health Care Facilities in Zimbabwe in 2020: A Mixed Methods Study

Chisare

2021

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Background: Tuberculosis preventive therapy (TPT) for latent TB infection has had limited success in Zimbabwe. The country plans to roll-out the three-month short-course TPT regimen (3HP) to address the implementation lag and poor uptake of the 6-9-month regimens. The study measured the level of organizational readiness while identifying barriers and facilitators to implement 3HP in four health facilities in Zimbabwe. Methods: A convergent, parallel mixed-methods approach was used to collect data from four primary healthcare clinics in Bulawayo and Harare Metropolitan provinces, Zimbabwe. Twenty healthcare providers completed a 35-item, self-administered questionnaire designed on a 5-point Likert scale and developed from the Weiner organizational readiness model. Nine of the providers and five TB program managers took part in 20-30 minute individual semi-structured key-informant interviews. Median scores with interquartile ranges were calculated wherein a score of 3.3 or greater indicated readiness. Differences between facilities were assessed using a Kruskal-Wallis rank test. Qualitative data on barriers and facilitators were transcribed and analyzed using a framework approach. Results: Readiness to implement 3HP across the four facilities was positive with a score of 3.8(IQR 3.3-4.1). The difference between the best 4.0(IQR 3.8-4.2) and worst performing facility 3.2(IQR 2.7-3.3) was 0.8 and statistically significant (p=0.039). The low facility score was due to poor contextual factors 2.5(IQR 2.0-3.3), task demands 2.6(IQR 2.3-2.9) and resource availability 2.1(IQR 1.5-2.5) scores. Key organizational readiness facilitators included healthcare provider and management buy-in; community willingness to generate demand for 3HP; strong collective capability through task-shifting, alignment with existing primary healthcare programs, perceived benefits, and need for 3HP. Barriers were negative past TPT experiences, suboptimal programmatic monitoring, inconsistent health provider remuneration, inadequate staffing, added workload, and an erratic supply chain across facilities. The organizational communication gap prompts the slow program implementation culture. Conclusions: The varied scores between facilities suggest distinct underlying conditions for readiness. Healthcare provider motivation is temporary based on the inconsistent resource supply, absence of TPT-specific monitoring and evaluation, and daily contextual challenges in facilities that must be addressed. Similar research is necessary for countries yet to implement 3HP to optimize the design or revision of delivery strategies and increase uptake of TPT. Keywords: Organizational readiness, TB preventive therapy, TPT, 3HP, Zimbabwe

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Section: Task Demandssupporting

confidence: 88%

Section: Discussionmentioning

confidence: 92%

Organizational Readiness for the Implementation of a Three-Month Short-Course TB Preventive Therapy Regimen (3HP) in Four Health Care Facilities in Zimbabwe in 2020: A Mixed Methods Study

Chisare

2021

Preprint

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“…This improvement may be attributable to improvements in healthcare system over time: better staffing and improved healthcare provider competence and confidence to manage persons with BC-PTB through mentorships and coaching, and better counseling among others. Elsewhere [38], healthcare providers indicated that tuberculosis clinics have been established across most health facilities to provide more time to understand and solve the challenges of persons with tuberculosis. This approach has led to better management of persons with tuberculosis.…”

Section: Discussionmentioning

confidence: 99%

Treatment success and mortality among adults with tuberculosis in rural eastern Uganda: a retrospective cohort study

2020

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Background Successful treatment of tuberculosis leads to clinical and public health benefits such as reduction in transmission, complications, and mortality among patients. However, data are limited on treatment outcomes and the associated factors among persons with bacteriologically confirmed pulmonary (BC-PTB) in rural areas of high dual tuberculosis and Human Immunodeficiency Virus (HIV) burden countries such as Uganda. We investigated factors associated with successful treatment of tuberculosis and mortality among adult persons with BC-PTB in rural eastern Uganda. Methods We constructed a retrospective cohort of persons with BC-PTB from a routine tuberculosis clinic database in eastern Uganda. We performed bivariate and multivariate analysis. Using a 5% level of significance, we ran a modified Poisson regression analysis to determine factors independently associated with treatment success and mortality rates. Results We retrieved 1123 records for persons with BC-PTB and the treatment outcomes were distributed as follows: 477(42.5%) cured, 323 (28.0%) treatment completed, 17(1.5%) treatment failed, 81(7.2%) died, 89(7.9%) lost to follow-up, and 136(12.1%) not evaluated. Overall, 800 (81.1%) of the 987 persons with BC-PTB that had treatment outcome, were successfully treated. Successful treatment of tuberculosis was less likely to occur among those with HIV infection (Adjusted risk ratio (aRR), 0.88; 95% Confidence Interval (CI), 0.82–0.95), older than 50 years (aRR, 0.89; 95% CI, 0.81–0.97), or male sex (aRR, 0.92; 95% CI, 0.87–0.98). Mortality was associated with HIV infection (aRR, 4.48; 95% CI, 2.95–6.79), older than 50 years (aRR, 2.93; 95% CI, 1.74–4.92), year of enrollment into treatment after 2015 (aRR, 0.80; 95% CI, 0.66–0.97), and Community-Based Directly Observed Therapy Short Course (aRR, 0.26; 95% CI, 0.13–0.50). Conclusions Treatment success rate among adult persons with BC-PTB in rural eastern Uganda is suboptimal and mortality rate is high. HIV infection and older age reduce chances of treatment success, and increase mortality rate. Older and HIV infected persons with BC-PTB will require special consideration to optimize treatment success rate and reduce mortality rate.

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Section: Discussionmentioning

confidence: 78%

“…A previous study in eastern Uganda reports that inadequate financing of the TB control program and deficiencies in the implementation of the CB-DOTS strategy is associated with suboptimal treatment success [16]. The study further showed that the disappearance of symptoms of TB especially after treatment initiation results in DTT [16]. Physical and economic barriers have been reported in a previous study as one of the reasons for not completing required sputum smear monitoring visits [17], emphasizing that people with TB face several barriers along the pathway to continuing with treatment.…”

Section: Discussionmentioning

confidence: 99%

Discontinuation of tuberculosis treatment among children in the Kampala Capital City Authority health facilities: a retrospective cohort study

Kibirige

Izudi

Okoboi

2021

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Introduction: Discontinuation of tuberculosis treatment (DTT) among children in sub-Saharan Africa is a major obstacle to effective tuberculosis (TB) control and has the potential to worsen the emergence of multi-drug resistant TB and death. DTT in children is understudied in Uganda. We examined the level and factors associated with DTT among children at four large health facilities in Kampala Capital City Authority and documented the reasons for DTT from treatment supporters and healthcare provider perspectives. Methods: We conducted a retrospective cohort analysis of records for children <15 years diagnosed and treated for TB between January 2018 and December 2019. We held focus group discussions with treatment supporters and key informant interviews with healthcare providers. We defined DTT as the stoppage of TB treatment for 30 or more consecutive days. We used a stepwise generalized linear model to assess factors independently associated with DTT and content analysis for the qualitative data reported using sub-themes. Results: Of 312 participants enrolled, 35 (11.2%) had discontinued TB treatment. The reasons for DTT included lack of privacy at healthcare facilities for children with TB and their treatment supporters, the disappearance of TB symptoms following treatment initiation, poor implementation of the community-based directly observed therapy short-course (CB-DOTS) strategy, insufficient funding to the TB program, and frequent stock-outs of TB drugs. DTT was more likely during the continuation phase of TB treatment compared to the intensive phase (Adjusted odds ratio (aOR), 5.22; 95% Confidence Interval (CI), 1.76-17.52) and when the treatment supporter was employed compared to when the treatment supporter was unemployed (aOR, 3.60; 95% CI, 1.34-11.38). Conclusion: Many children with TB discontinue TB treatment and this might exacerbate TB morbidity and mortality. Treatment supporters of children with TB should be provided with detailed and consistent health education messages about TB treatment duration, the benefits of treatment completion, and risks of treatment discontinuation. The district and national TB control programs should address gaps in funding to TB care and the supply of TB drugs.

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Explaining the successes and failures of tuberculosis treatment programs; a tale of two regions in rural Eastern Uganda

Cited by 3 publications

References 10 publications

Organizational Readiness for the Implementation of a Three-Month Short-Course TB Preventive Therapy Regimen (3HP) in Four Health Care Facilities in Zimbabwe in 2020: A Mixed Methods Study

Organizational Readiness for the Implementation of a Three-Month Short-Course TB Preventive Therapy Regimen (3HP) in Four Health Care Facilities in Zimbabwe in 2020: A Mixed Methods Study

Treatment success and mortality among adults with tuberculosis in rural eastern Uganda: a retrospective cohort study

Discontinuation of tuberculosis treatment among children in the Kampala Capital City Authority health facilities: a retrospective cohort study

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