Gridlock from Diagnosis to Treatment of Multidrug-Resistant Tuberculosis (MDR-TB) in Tanzania: Illuminating Potential Factors for Possible Intervention

Liyoyo, Alphonce A; Heysell, Scott K; Kisonga, Riziki; Lyimo, Johnson; Mleoh, Liberate; Mutayoba, Beatrice; Lekule, Isaack A.; Mmbaga, Blandina T.; Kibiki, Gibson; Mpagama, Stellah

doi:10.24248/eahrj.v1i1.385

Cited by 3 publications

(3 citation statements)

References 21 publications

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“…4 This sobering fact has been illuminated in Tanzanian research studies that uncovered a health system gridlock largely contributed by limited resources and skills-training for front-line healthcare providers, and weak linkage to other health services with the subsequent effect of underuse of technologies. [5][6][7][8][9] Likewise, the prevalence of dual communicable and NCD epidemics is increasing, yet communicable clinics are unprepared to deal with dual services. 10 11 For instance, the prevalence of diabetes mellitus (DM) ranged 4%-17% and hypertension ranged 7%-25% in people leaving with HIV attending clinics in Tanzania cities, while, in other settings within Tanzania, the prevalence of DM ranged 4%-5% and hypertension ranged 22%-30%.…”

Section: Introductionmentioning

confidence: 99%

Protocol for establishing an Adaptive Diseases control Expert Programme in Tanzania (ADEPT) for integrating care of communicable and non-communicable diseases using tuberculosis and diabetes as a case study

Mpagama¹,

Ramaiya

Lillebæk

et al. 2021

BMJ Open

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IntroductionMost sub-Saharan African countries endure a high burden of communicable infections but also face a rise of non-communicable diseases (NCDs). Interventions targeting particular epidemics are often executed within vertical programmes. We establish an Adaptive Diseases control Expert Programme in Tanzania (ADEPT) model with three domains; stepwise training approach, integration of communicable and NCDs and a learning system. The model aims to shift traditional vertical programmes to an adaptive diseases management approach through integrating communicable and NCDs using the tuberculosis (TB) and diabetes mellitus (DM) dual epidemic as a case study. We aim to describe the ADEPT protocol with underpinned implementation and operational research on TB/DM.Methods and analysisThe model implement a collaborative TB and DM services protocol as endorsed by WHO in Tanzania. Evaluation of the process and outcomes will follow the logic framework. A mixed research design with both qualitative and quantitative approaches will be used in applied research action. Anticipated implementation research outcomes include at the health facilities level for organising TB/DM services, pathways of patients with TB/DM seeking care in different health facilities, factors in service delivery that need deimplementation and the ADEPT model implementation feasibility, acceptability and fidelity. Expected operational research outcomes include additional identified patients with dual TB/DM, the prevalence of comorbidities like hypertension in patients with TB/DM and final treatment outcomes of TB/DM including treatment-related complications. Findings will inform the future policies and practices for integrating communicable and NCDs services.Ethics and disseminationEthical approval was granted by The National Research Health Ethical Committee (Ref-No. NIMR/HQ/R.8a/Vol.IX/2988) and the implementation endorsed by the government authorities. Findings will be proactively disseminated through multiple mechanisms including peer-reviewed journals, and engagement with various stakeholders’ example in conferences and social media.

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Section: Introductionmentioning

confidence: 99%

Protocol for establishing an Adaptive Diseases control Expert Programme in Tanzania (ADEPT) for integrating care of communicable and non-communicable diseases using tuberculosis and diabetes as a case study

Mpagama¹,

Ramaiya

Lillebæk

et al. 2021

BMJ Open

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“…At the health centre level, the median (IQR) individuals with TB diagnosed in the year 2020 at the intervention facilities was 330 (42-524) and control facilities was 330 (38-557) (p = 0.29), whereas the median (IQR) individuals with DM attending the services in the same time period was 160 (0-757) in intervention facilities and 60 (0-1598) control health centres (p = 0.89). Individuals were more often identified with dual TB and DM at the intervention hospitals with a median of eight (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) individuals per facility compared with a median of one individual per control facility 1 (0-3) (p = 0.02). The same trend was observed in health centres; dual TB and DM was diagnosed in a median of four individuals (4-5) per facility in intervention facilities compared to none at any of the control facilities (p = 0.01).…”

Section: Resultsmentioning

confidence: 99%

“…Such recommendations and guidelines also suggest the benefit of integrating services for NCDs with TB and HIV care, but this has not been accomplished in Tanzania [11]. For instance, the introduction of molecular diagnostics for multidrug resistant (MDR)-TB in Tanzania did not translate into a reduction of mortality as described elsewhere [12], prompting a nationwide examination of barriers and bottlenecks [13]. Importantly, this examination found that most of the front-line health care providers in TB and HIV clinics did not regularly receive continuous on-the-job medical education and therefore lacked updated knowledge and skills on the international standards of TB care.…”

Section: Introductionmentioning

confidence: 99%

Implementing Innovative Approaches to Improve Health Care Delivery Systems for Integrating Communicable and Non-Communicable Diseases Using Tuberculosis and Diabetes as a Model in Tanzania

Mpagama,

Byashalira,

Chamba

et al. 2023

IJERPH

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Background: Many evidence-based health interventions, particularly in low-income settings, have failed to deliver the expected impact. We designed an Adaptive Diseases Control Expert Programme in Tanzania (ADEPT) to address systemic challenges in health care delivery and examined the feasibility, acceptability and effectiveness of the model using tuberculosis (TB) and diabetes mellitus (DM) as a prototype. Methods: This was an effectiveness-implementation hybrid type-3 design that was implemented in Dar es Salaam, Iringa and Kilimanjaro regions. The strategy included a stepwise training approach with web-based platforms adapting the Gibbs’ reflective cycle. Health facilities with TB services were supplemented with DM diagnostics, including glycated haemoglobin A1c (HbA1c). The clinical audit was deployed as a measure of fidelity. Retrospective and cross-sectional designs were used to assess the fidelity, acceptability and feasibility of the model. Results: From 2019–2021, the clinical audit showed that ADEPT intervention health facilities more often identified median 8 (IQR 6–19) individuals with dual TB and DM, compared with control health facilities, median of 1 (IQR 0–3) (p = 0.02). Likewise, the clinical utility of HbA1c on intervention sites was 63% (IQR:35–75%) in TB/DM individuals compared to none in the control sites at all levels, whereas other components of the standard of clinical management of patients with dual TB and DM did not significantly differ. The health facilities showed no difference in screening for additional comorbidities such as hypertension and malnutrition. The stepwise training enrolled a total of 46 nurse officers and medical doctors/specialists for web-based training and 40 (87%) attended the workshop. Thirty-one (67%), 18 nurse officers and 13 medical doctors/specialists, implemented the second step of training others and yielded a total of 519 additional front-line health care workers trained: 371 nurses and 148 clinicians. Overall, the ADEPT model was scored as feasible by metrics applied to both front-line health care providers and health facilities. Conclusions: It was feasible to use a stepwise training and clinical audit to support the integration of TB and DM management and it was largely acceptable and effective in differing regions within Tanzania. When adapted in the Tanzania health system context, the model will likely improve quality of services.

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Gridlock from diagnosis to treatment of multidrug resistant tuberculosis (MDR-TB) in Tanzania: patients’ perspectives from a focus group discussion

et al. 2020

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Background Molecular diagnostics have revolutionized the diagnosis of multidrug resistant tuberculosis (MDR-TB). Yet in Tanzania we found delay in diagnosis with more than 70% of MDR-TB patients having a history of several previous treatment courses for TB signaling prior opportunities for diagnosis. We aimed to explore patients’ viewpoints and experiences with personal and socio-behavioral obstacles from MDR-TB diagnosis to treatment in an attempt to understand these prior findings. Methods The study was conducted in December 2016 with MDR-TB patients admitted at Kibong’oto Infectious Diseases Hospital. A qualitative approach deploying focus group discussions (FGDs) was used to gather information. Groups were sex aggregated to allow free interaction and to gauge gender specific issues in the social and behavioral contexts. The FGDs explored pathways and factors in the service delivery that may have contributed in the delay in accessing MDR-TB diagnostics and/or treatment. Collected data were coded, categorized and thematically interpreted. Results Forty MDR-TB patients participated in six FGDs. Challenges and barriers contributing to the delay in accessing MDR-TB diagnosis to treatment were as follows: 1) Participants had a different understanding of MDR-TB that led to seeking services outside the conventional health system; 2) Socio-economic adversity made health-seeking behavior difficult and often unproductive; 3) In the health system, challenges included inadequacy of MDR-TB diagnostic centers, lack of knowledge on behalf of health care providers to consider MDR-TB and order appropriate diagnostics; 4) The specimen referral system for early diagnosis of MDR-TB was inefficient. Non-adherence of TB patients to first-line anti-TB drugs prior to MDR-TB diagnosis, given the multitude of barriers discussed, was coupled with both intentional and unintentional non-adherence of health care providers to international standards of TB care. Conclusion Patient-centered strategies bridging communities and the health system are urgently required for optimum MDR-TB control in Tanzania.

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Gridlock from Diagnosis to Treatment of Multidrug-Resistant Tuberculosis (MDR-TB) in Tanzania: Illuminating Potential Factors for Possible Intervention

Cited by 3 publications

References 21 publications

Protocol for establishing an Adaptive Diseases control Expert Programme in Tanzania (ADEPT) for integrating care of communicable and non-communicable diseases using tuberculosis and diabetes as a case study

Protocol for establishing an Adaptive Diseases control Expert Programme in Tanzania (ADEPT) for integrating care of communicable and non-communicable diseases using tuberculosis and diabetes as a case study

Implementing Innovative Approaches to Improve Health Care Delivery Systems for Integrating Communicable and Non-Communicable Diseases Using Tuberculosis and Diabetes as a Model in Tanzania

Gridlock from diagnosis to treatment of multidrug resistant tuberculosis (MDR-TB) in Tanzania: patients’ perspectives from a focus group discussion

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