Isoniazid Preventive Therapy among Children Living with Tuberculosis Patients: Is It Working? A Mixed-Method Study from Bhopal, India

Abstract

ObjectiveWe assessed uptake of isoniazid preventive therapy (IPT) among child contacts of smear-positive tuberculosis (TB) patients and its implementation challenges from healthcare providers’ and parents’ perspectives in Bhopal, India.MethodsA mixed-method study design: quantitative phase (review of programme records and house-to-house survey of smear-positive TB patients) followed by qualitative phase (interviews of healthcare providers and parents).ResultsOf 59 child contacts (<6 years) of 129 index patients, 51 were contacted. Among them, 19 of 51 (37%) were screened for TB and one had TB. Only 11 of 50 (22%) children were started and 10 of 50 (20%) completed IPT. Content analysis of interviews revealed lack of awareness, risk perception among parents, cumbersome screening process, isoniazid stock-outs, inadequate knowledge among healthcare providers and poor programmatic monitoring as main barriers to IPT implementation.ConclusionNational TB programme should counsel parents, train healthcare providers, simplify screening procedures, ensure regular drug supply and introduce an indicator to strengthen monitoring and uptake of IPT.

Barriers to the implementation of isoniazid preventive therapy for tuberculosis in children in endemic settings: A review

“…In many cultures, preventive treatments are not endorsed and the misconception exists that you do not need medicines if you do not feel sick . Even after receiving health education, many caregivers in the studies reviewed were reluctant to take their children in for screening or IPT initiation because they felt they were healthy and asymptomatic . This is a difficult point of understanding to alter.…”

“…In order for patients and caregivers to be better informed about their health risks and treatment options, health‐care workers must be knowledgeable and educated about the medications and services they offer, prescribe and monitor. A large proportion of the studies reviewed showed that this was generally not the case, with significant gaps in health‐care worker knowledge about the nature and benefits of IPT . This translates into poor understanding and poor uptake by patients.…”

“…Education is an important issue but it is not the only impediment faced by health‐care workers trying to deliver IPT to children in TB‐endemic settings. Some health‐care centres lacked the equipment to rule out active TB, which they saw as necessary to initiating IPT, while others encountered supply chain difficulties in procuring sufficient isoniazid to provide patients . The labour‐intensive preparation of paediatric doses was reported as placing additional strain on already stretched staffing arrangements in some areas although child‐friendly dispersible formulations are now becoming available in most countries through the Global Development Fund .…”

“…Some health‐care centres lacked the equipment to rule out active TB, which they saw as necessary to initiating IPT, while others encountered supply chain difficulties in procuring sufficient isoniazid to provide patients . The labour‐intensive preparation of paediatric doses was reported as placing additional strain on already stretched staffing arrangements in some areas although child‐friendly dispersible formulations are now becoming available in most countries through the Global Development Fund . Centres also often eschewed from recommending monthly monitoring, as advised by the WHO, complicating efforts to track and encourage adherence .…”

“…The labour‐intensive preparation of paediatric doses was reported as placing additional strain on already stretched staffing arrangements in some areas although child‐friendly dispersible formulations are now becoming available in most countries through the Global Development Fund . Centres also often eschewed from recommending monthly monitoring, as advised by the WHO, complicating efforts to track and encourage adherence . The lack of prioritisation for IPT by government in some areas, adds another layer of difficulty to the effective implementation of these programmes, particularly in resource‐poor regions where health systems are in need of broad strengthening across multiple areas…”