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

Abstract

Background 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. 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. Methods Theory-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. Results Delayed 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. Conclusions Delayed 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

GeneXpert rollout in three high-burden tuberculosis countries in Africa: A review of pulmonary tuberculosis diagnosis and outcomes from 2001 to 2019

“…Major health system barriers include laboratory-running challenges such as intermittent electricity supply and limited number of Xpert cartridges, insufficient human resources, poor provider knowledge and skills to adhere to diagnostic guidelines and inadequate information management. 30 , 31 , 32 On the patient side, barriers include loss to follow-up due to delayed diagnosis or family and work commitments, negative public sector care perceptions, and using private-sector care with limited financial resources. 33 , 34 …”

Applying learning health systems thinking in codeveloping integrated tuberculosis interventions in the contexts of COVID-19

“…Facility-level routine TB data elements and indicators (monthly and quarterly breakdown of data elements according to the TB programme cascade, from screening, testing, to treatment, both total numbers and rates: people screened for TB symptoms; TB symptomatic clients testing positive; TB symptomatic clients with sputum sent; and TB clients started on treatment) from four preceding reporting quarters were extracted from the DHIS to further help identify possible health system bottlenecks. 27 ToC as planning tool An LHS lens is applied to describe health system planning and implementation activities using ToC as a tool. ToC is an interactive, collaborative process that draws from a range of methods and data sources, describing how a programme intends to reach specific outcomes through a logical sequence of short-term and mediumterm steps.…”

“…A key aspect of the approach adopted is the initial, P2D phase, which offered a diagnosis of the challenges and opportunities for strengthening in the district. The methods of this particular phase has been described elsewhere, 27 but are summarised here for context. Three data sources were used to develop an initial snapshot of TB care in the district.…”

“…This was further supported by a review of an internal TB mortality report of Amajuba. Facility-level routine TB data elements and indicators (monthly and quarterly breakdown of data elements according to the TB programme cascade, from screening, testing, to treatment, both total numbers and rates: people screened for TB symptoms; TB symptomatic clients testing positive; TB symptomatic clients with sputum sent; and TB clients started on treatment) from four preceding reporting quarters were extracted from the DHIS to further help identify possible health system bottlenecks 27…”

“…The study was conceived as a sequential partially mixed methods study,24 comprising two work phases: (1) a diagnostic phase consisting of a scoping review, a situational analysis of a number of PHC facilities, formative semistructured interviews with key stakeholders, non-clinical observations in health facilities and (2) an intervention development, adaptation and piloting phase, involving the formulation of a ToC and codesigning and refining proposed interventions, piloting and evaluating codesigned interventions in PHC facilities 25. Outputs from the diagnostic phase are described elsewhere,26 27 and in this paper, focus is placed on the participatory formulation of a ToC and codesign process for the development of interventions which underpinned both phases of the research.…”