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The Institute for Global Health and Development

Permanent URI for this collectionhttps://eresearch.qmu.ac.uk/handle/20.500.12289/9

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Author: search.filters.author.Grant, Alison D

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    Qualitative system dynamics modelling to support the design and implementation of tuberculosis infection prevention and control measures in South African primary health care facilities
    (Oxford University Press (OUP), 2024-08-31) Diaconu, Karin; Karat, Aaron; Bozzani, Fiametta; McCreesh, Nicky; Falconer, Jennifer; Voce, Anna; Vassall, Anna; Grant, Alison D; Kielmann, Karina
    Tuberculosis infection prevention and control (TB IPC) measures are a cornerstone of policy, but measures are diverse and variably implemented. Limited attention has been paid to the health system environment which influences successful implementation of these measures. We used qualitative system dynamics and group-model-building methods 1) develop a qualitative causal map of the interlinked drivers of Mycobacterium tuberculosis (Mtb) transmission in South African primary health care facilities which in turn, helped us to 2) identify plausible IPC interventions to reduce risk of transmission. Two one-day participatory workshops were held in 2019 with policy- and decision-makers at national and provincial level, and patient advocates and health professionals at clinic and district level. Causal loop diagrams were generated by participants and combined by investigators. The research team reviewed diagrams to identify the drivers of nosocomial transmission of Mtb in primary health care facilities. Interventions proposed by participants were mapped onto diagrams to identify anticipated mechanisms of action and effect. Three systemic drivers were identified: 1) Mtb nosocomial transmission is driven by bottlenecks in patient flow at given times; 2) IPC implementation and clinic processes are anchored within a staff “culture of nominal compliance”; and 3) limited systems-learning at policy level inhibits effective clinic management and IPC implementation. Interventions prioritised by workshop participants included infrastructural, organisational, and behavioural strategies that target three areas: 1) improve air quality; 2) improve use of personal protective equipment; and 3) reduce the number of individuals in the clinic. In addition to core mechanisms, participants elaborated specific additional enablers that would help sustain implementation. Qualitative system dynamics modelling (SDM) methods allowed us to capture stakeholder views and potential solutions to address the problem of sub-optimal TB IPC implementation. The participatory elements of SDM facilitated problem-solving and inclusion of multiple factors frequently neglected when considering implementation.
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    Cost-effectiveness of tuberculosis infection prevention and control interventions in South African clinics: a model-based economic evaluation informed by complexity science methods
    (BMJ Publishing Group, 2023-02-15) Bozzani, Fiammetta Maria; McCreesh, Nicky; Diaconu, Karin; Govender, Indira; White, Richard G; Kielmann, Karina; Grant, Alison D; Vassall, Anna
    Introduction: Nosocomial Mycobacterium tuberculosis (Mtb) transmission substantially impacts health workers, patients and communities. Guidelines for tuberculosis infection prevention and control (TB IPC) exist but implementation in many settings remains suboptimal. Evidence is needed on cost-effective investments to prevent Mtb transmission that are feasible in routine clinic environments. Methods: A set of TB IPC interventions was codesigned with local stakeholders using system dynamics modelling techniques that addressed both core activities and enabling actions to support implementation. An economic evaluation of these interventions was conducted at two clinics in KwaZulu-Natal, employing agent-based models of Mtb transmission within the clinics and in their catchment populations. Intervention costs included the costs of the enablers (eg, strengthened supervision, community sensitisation) identified by stakeholders to ensure uptake and adherence. Results: All intervention scenarios modelled, inclusive of the relevant enablers, cost less than US$200 per disability-adjusted life-year (DALY) averted and were very cost-effective in comparison to South Africa’s opportunity cost-based threshold (US$3200 per DALY averted). Two interventions, building modifications to improve ventilation and maximising use of the existing Central Chronic Medicines Dispensing and Distribution system to reduce the number of clinic attendees, were found to be cost saving over the 10-year model time horizon. Incremental cost-effectiveness ratios were sensitive to assumptions on baseline clinic ventilation rates, the prevalence of infectious TB in clinic attendees and future HIV incidence but remained highly cost-effective under all uncertainty analysis scenarios. Conclusion: TB IPC interventions in clinics, including the enabling actions to ensure their feasibility, afford very good value for money and should be prioritised for implementation within the South African health system.
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    The role of emergent champions in policy implementation for decentralised drug-resistant tuberculosis care in South Africa
    (BMJ Publishing Group, 2022-12-09) Le Roux, Sacha Roxanne; Jassat, Waasila; Dickson, Lindy; Mitrani, Leila; Cox, Helen; Mlisana, Koleka; Black, John; Loveday, Marian; Grant, Alison D; Moshabela, Mosa; Kielmann, Karina; Nicol, Mark P
    Objective: Champions are recognised as important to driving organisational change in healthcare quality improvement initiatives in high-income settings. In low-income and middle-income countries with a high disease burden and constrained human resources, their role is highly relevant yet understudied. Within a broader study on policy implementation for decentralised drug-resistant tuberculosis care in South Africa, we characterised the role, strategies and organisational context of emergent policy champions. Design: Interviews with 34 healthcare workers in three South African provinces identified the presence of individuals who had a strong influence on driving policy implementation forward. Additional interviews were conducted with 13 participants who were either identified as champions in phase II or were healthcare workers in facilities in which the champions operated. Thematic analyses using a socio-ecological framework further explored their strategies and the factors enabling or obstructing their agency. Results: All champions occupied senior managerial posts and were accorded legitimacy and authority by their communities. ‘Disease-centred’ champions had a high level of clinical expertise and placed emphasis on clinical governance and clinical outcomes, while ‘patient-centred’ champions promoted pathways of care that would optimise patients’ recovery while minimising disruption in other spheres of their lives. Both types of champions displayed high levels of resourcefulness and flexibility to adapt strategies to the resource-constrained organisational context. Conclusion: Policymakers can learn from champions’ experiences regarding barriers and enablers to implementation to adapt policy. Research is needed to understand what factors can promote the sustainability of champion-led policy implementation, and to explore best management practices to support their initiatives.