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Start date: 1992Subject: search.filters.subject.Tuberculosis

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    Decentralising DR-TB care: the trade-off between quality of care and service coverage in the early phase of implementation
    (International Union Against Tuberculosis and Lung Disease, 2025-09-03) Jassat, Waasila; Moshabela, Mosa; Nicol, Mark P.; Dickson, Laurie; Cox, Helen; Mlisana, Koleka; Black, John; Loveday, Marian; Grant, Alison D.; Kielmann, Karina; Schneider, Hans G.
    A policy of decentralised care for drug-resistant TB (DR-TB) was introduced in South Africa in 2011. We describe a trade-off between increasing coverage of services and poor quality of care, in the early phase of policy implementation. This was a mixed methods case study, comparing implementation in KwaZulu-Natal and Western Cape provinces; with interviews and quantitative analysis of routine DR-TB programme data. We analysed qualitative data, thematically organizing findings into inputs, processes, and outputs to explore how decentralisation influenced quality of DR-TB care. Decentralisation of DR-TB care expanded access across provinces but there was wide variation in pace, planning and structural readiness. Where rapid scale-up outpaced capacity-building, weaknesses in resourcing, workforce, and clinical governance compromised quality of care. Two illustrative examples highlight that decentralisation to inadequately resourced sites resulted in morbidity to patients who did not receive effective monitoring for adverse events; and decentralising services to inadequately capacitated clinicians resulted in incorrect initiation in more complex cases and late referral of clinical complications. Attempts to decentralise DR-TB treatment in the context of complex treatment algorithms and limited health system capacity resulted in trade-offs of care quality. We argue that quality of care should be an essential consideration in early implementation of health programmes.
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    Development and description of a theory-driven, evidence-based, complex intervention to improve adherence to treatment for tuberculosis in the UK: the IMPACT study
    (Informa UK Limited, 2023-11-27) Jones, Annie S. K.; Horne, Rob; White, Jacqui; Costello, Trish; Darvell, Marcia; Karat, Aaron S.; Kielmann, Karina; Stagg, Helen R.; Hill, Adam T.; Kunst, Heinke; Campbell, Colin N. J.; Lipman, Marc C. I.
    Background Tuberculosis (TB) has a significant treatment burden for patients, requiring at least six months of anti-TB treatment (ATT) with multiple medicines. Ensuring good adherence to ATT is central to global TB strategies, including those in high-income, low-TB incidence (HILI) settings. For adherence interventions to be successful and deliverable, they need to address the personal and environmental factors influencing patient and provider behaviour. Purpose This paper describes the application of theory and research evidence to inform the design process of the IMPACT manualised intervention to support ATT adherence for adults with TB disease in the United Kingdom (UK). It also provides a full description of the resulting intervention. Methods We synthesised findings from our formative research (qualitative and quantitative scoping reviews and patient and carer interviews) and supplemented these with clinic observations, a literature review, and healthcare provider interviews. Findings were mapped to the guiding theoretical framework (Perceptions and Practicalities Approach) which was operationalised to design the intervention components and content. An Intervention Development Group (IDG) of relevant stakeholders were consulted to adapt the intervention to local clinical settings. Results The pragmatic, deliverable components and content for the IMPACT intervention included: (1) an enhanced, structured, risk assessment to systematically identify risk factors for non-adherence plus locally-adapted guidance to mitigate these; and (2) patient educational materials (an animated video and interactive patient booklet) about TB and its treatment, to communicate the need for treatment and address common concerns. Conclusions Using a theory– and evidence– based approach incorporating stakeholder input, we have developed a multi-component, pragmatic, manualised intervention, which addresses patients’ personal barriers to adherence within local service resources to improve adherence to ATT within UK TB services.
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    Organisation of care for people receiving drug-resistant tuberculosis treatment in South Africa: a mixed methods study
    (BMJ Publishing Group, 2023-11-18) Dickson, Lindy; Le Roux, Sacha Roxanne; Mitrani, Leila; Hill, Jeremy; Jassat, Waasila; Cox, Helen; Mlisana, Koleka; Black, John; Loveday, Marian; Grant, Alison; Kielmann, Karina; Ndjeka, Norbert; Moshabela, Mosa; Nicol, Mark
    Objectives: Treatment for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) is increasingly transitioning from hospital-centred to community-based care. A national policy for decentralised programmatic MDR/RR-TB care was adopted in South Africa in 2011. We explored variations in the implementation of care models in response to this change in policy, and the implications of these variations for people affected by MDR/RR-TB. Design: A mixed methods study was done of patient movements between healthcare facilities, reconstructed from laboratory records. Facility visits and staff interviews were used to determine reasons for movements. Participants and setting: People identified with MDR/RR-TB from 13 high-burden districts within South Africa. Outcome measures: Geospatial movement patterns were used to identify organisational models. Reasons for patient movement and implications of different organisational models for people affected by MDR/RR-TB and the health system were determined. Results: Among 191 participants, six dominant geospatial movement patterns were identified, which varied in average hospital stay (0–281 days), average patient distance travelled (12–198 km) and number of health facilities involved in care (1–5 facilities). More centralised models were associated with longer delays to treatment initiation and lengthy hospitalisation. Decentralised models facilitated family-centred care and were associated with reduced time to treatment and hospitalisation duration. Responsiveness to the needs of people affected by MDR/RR-TB and health system constraints was achieved through implementation of flexible models, or the implementation of multiple models in a district. Conclusions: Understanding how models for organising care have evolved may assist policy implementers to tailor implementation to promote particular patterns of care organisation or encourage flexibility, based on patient needs and local health system resources. Our approach can contribute towards the development of a health systems typology for understanding how policy-driven models of service delivery are implemented in the context of variable resources.
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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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    Estimating the contribution of transmission in primary healthcare clinics to community-wide TB disease incidence, and the impact of infection prevention and control interventions, in KwaZulu-Natal, South Africa
    (BMJ, 2022-04-08) McCreesh, Nicky; Karat, Aaron S.; Govender, Indira; Baisley, Kathy; Diaconu, Karin; Yates, Tom A.; Houben, Rein M. G. J.; Kielmann, Karina; Grant, Alison D.; White, Richard
    Background: There is a high risk of Mycobacterium tuberculosis (Mtb) transmission in healthcare facilities in high burden settings. WHO guidelines on tuberculosis (TB) infection prevention and control (IPC) recommend a range of measures to reduce transmission in healthcare settings. These were evaluated primarily based on evidence for their effects on transmission to healthcare workers in hospitals. To estimate the overall impact of IPC interventions, it is necessary to also consider their impact on community-wide TB incidence and mortality. Methods: We developed an individual-based model of Mtb transmission in households, primary healthcare (PHC) clinics, and all other congregate settings. The model was parameterised using data from a high HIV prevalence community in South Africa, including data on social contact by setting, by sex, age, and HIV/antiretroviral therapy status; and data on TB prevalence in clinic attendees and the general population. We estimated the proportion of disease in adults that resulted from transmission in PHC clinics, and the impact of a range of IPC interventions in clinics on community-wide TB. Results: We estimate that 7.6% (plausible range 3.9%–13.9%) of non-multidrug resistant and multidrug resistant TB in adults resulted directly from transmission in PHC clinics in the community in 2019. The proportion is higher in HIV-positive people, at 9.3% (4.8%–16.8%), compared with 5.3% (2.7%–10.1%) in HIV-negative people. We estimate that IPC interventions could reduce incident TB cases in the community in 2021–2030 by 3.4%–8.0%, and deaths by 3.0%–7.2%. Conclusions: A non-trivial proportion of TB results from transmission in clinics in the study community, particularly in HIV-positive people. Implementing IPC interventions could lead to moderate reductions in disease burden. We recommend that IPC measures in clinics should be implemented for their benefits to staff and patients, but also for their likely effects on TB incidence and mortality in the surrounding community.
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    Tuberculosis infection among youths in overcrowded university hostels in Kenya: A cross-sectional study
    (2021-12-28) Maina, Teresia; Willetts, Annie; Ngari, Moses; Osman, Abdullahi
    Tuberculosis (TB) remains a top global health problem and its transmission rate among contacts is higher when they are cohabiting with a person who is sputum smear-positive. Our study aimed to describe the prevalence of TB among student contacts in the university and determine factors associated with TB transmission. We performed a cross-sectional study with an active contact case finding approach among students receiving treatment at Kilifi County Hospital from January 2016 to December 2017. The study was conducted in a public university in Kilifi County, a rural area within the resource-limited context of Kenya. The study population included students attending the university and identified as sharing accommodation or off-campus hostels, or a close social contact to an index case. The index case was defined as a fellow university student diagnosed with TB at the Kilifi County Hospital during the study period. Contacts were traced and tested for TB using GeneXpert. Among the 57 eligible index students identified, 51 (89%) agreed to participate. A total of 156 student contacts were recruited, screened and provided a sputum sample. The prevalence of TB (GeneXpert test positive/clinical diagnosis) among all contacts was 8.3% (95% CI 4.5-14%). Among the 8.3% testing positive 3.2% (95% CI 1.0-7.3%) were positive for GeneXpert only. Sharing a bed with an index case was the only factor significantly associated with TB infection. No other demographic or clinical factor was associated with TB infection. Our study identified a high level of TB transmission among university students who had contact with the index cases. The study justifies further research to explore the genetic sequence and magnitude of TB transmission among students in overcrowded university in resource limited contexts.
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    Organisational culture and mask-wearing practices for tuberculosis infection prevention and control among health care workers in primary care facilities in the Western Cape, South Africa: A qualitative study
    (MDPI, 2021-11-19) Kallon, Idriss I.; Swartz, Alison; Colvin, Christopher J.; MacGregor, Hayley; Zwama, Gimenne; Voce, Anna S.; Grant, Alison D.; Kielmann, Karina
    Background: Although many healthcare workers (HCWs) are aware of the protective role that mask-wearing has in reducing transmission of tuberculosis (TB) and other airborne diseases, studies on infection prevention and control (IPC) for TB in South Africa indicate that mask-wearing is often poorly implemented. Mask-wearing practices are influenced by aspects of the environment and organisational culture within which HCWs work. Methods: We draw on 23 interviews and four focus group discussions conducted with 44 HCWs in six primary care facilities in the Western Cape Province of South Africa. Three key dimensions of organisational culture were used to guide a thematic analysis of HCWs’ perceptions of masks and mask-wearing practices in the context of TB infection prevention and control. Results: First, HCW accounts address both the physical experience of wearing masks, as well as how mask-wearing is perceived in social interactions, reflecting visual manifestations of organisational culture in clinics. Second, HCWs expressed shared ways of thinking in their normalisation of TB as an inevitable risk that is inherent to their work and their localization of TB risk in specific areas of the clinic. Third, deeper assumptions about mask-wearing as an individual choice rather than a collective responsibility were embedded in power and accountability relationships among HCWs and clinic managers. These features of organisational culture are underpinned by broader systemic shortcomings, including limited availability of masks, poorly enforced protocols, and a general lack of role modelling around mask-wearing. HCW mask-wearing was thus shaped not only by individual knowledge and motivation but also by the embodied social dimensions of mask-wearing, the perceptions that TB risk was normal and localizable, and a shared underlying tendency to assume that mask-wearing, ultimately, was a matter of individual choice and responsibility. Conclusions: Organisational culture has an important, and under-researched, impact on HCW mask-wearing and other PPE and IPC practices. Consistent mask-wearing might become a more routine feature of IPC in health facilities if facility managers more actively promote engagement with TB-IPC guidelines and develop a sense of collective involvement and ownership of TB-IPC in facilities.
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    Modelling the effect of infection prevention and control measures on rate of Mycobacterium tuberculosis transmission to clinic attendees in primary health clinics in South Africa
    (BMJ, 2021-10-25) McCreesh, Nicky; Karat, Aaron S.; Baisley, Kathy; Diaconu, Karin; Bozzani, Fiammetta; Govender, Indira; Beckwith, Peter; Yates, Tom A.; Deol, Arminder K.; Houben, Rein M. G. J.; Kielmann, Karina; White, Richard G.; Grant, Alison D.
    Background Elevated rates of tuberculosis in health care workers demonstrate the high rate of Mycobacterium tuberculosis (Mtb) transmission in health facilities in high burden settings. In the context of a project taking a whole systems approach to tuberculosis infection prevention and control (IPC), we aimed to evaluate the potential impact of conventional and novel IPC measures on Mtb transmission to patients and other clinic attendees.
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    Relational dynamics of treatment behavior among individuals with tuberculosis in high-income countries: A scoping review
    (Dove Press, 2021-09-21) Arakelyan, Stella; Karat, Aaron S.; Jones, Annie S. K.; Vidal, Nicole L.; Stagg, Helen R.; Darvell, Marcia; Horne, Rob; Lipman, Marc C. I.; Kielmann, Karina
    Although tuberculosis (TB) incidence has significantly declined in high-income, low-incidence (HILI) countries, challenges remain in managing TB in vulnerable populations who may struggle to stay on anti-TB treatment (ATT). Factors associated with non-adherence to ATT are well-documented; however, adherence is often narrowly conceived as a fixed binary variable that places emphasis on individual agency and the act of taking medicines, rather than on the demands of being on treatment more broadly. Further, the mechanisms through which documented factors act upon the experience of ‘being on treatment’ are poorly understood. Adopting a relational approach that emphasizes the embeddedness of individuals within dynamic social, structural, and systems contexts, this scoping review aims to synthesize qualitative evidence on experiences of being on ATT and mechanisms through which socio-ecological factors influence adherence in HILI countries. Six electronic databases were searched for peer-reviewed literature published in English between January 1990 and May 2020. Additional studies were obtained by searching references and citations of included studies. Narrative synthesis was used to analyze qualitative data extracted from included studies. Of 28 included studies, the majority (86%) reported on health systems factors, followed by personal characteristics (82%), structural influences (61%), social factors (57%), and treatment-related factors (50%). Included studies highlighted three points that underpin a relational approach to ATT behavior: (1) individual motivation and capacity to take ATT is dynamic and intertwined with, rather than separate from, social, health systems, and structural factors; (2) individuals’ pre-existing experiences of health-seeking influenced their views on treatment and their ability to commit to long-term regular medicine-taking; and (3) social, cultural, and political contexts play an important role in mediating how specific factors work to support or hinder ATT adherence behavior in different settings. Based on our analysis, we suggest that person-centered clinical management of tuberculosis should (a) acknowledge the ways in which ATT both disrupts and is managed within the everyday lives of individuals with TB; (b) appreciate that circumstances and the support and resources that individuals can access may change over the course of treatment; and (c) display sensitivity towards context-specific social and cultural norms affecting individual and collective experiences of being on ATT.
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    How do participatory methods shape policy? Applying a realist approach to the formulation of a new tuberculosis policy in Georgia
    (2021-06-29) Marchal, Bruno; Abejirinde, Ibukun-Oluwa Omolade; Sulaberidze, Lela; Chikovani, Ivdity; Uchaneishvili, Maia; Shengelia, Natia; Diaconu, Karin; Vassall, Anna; Zoidze, Akaki; Giralt, Ariadna Nebot; Witter, Sophie
    This paper presents the iterative process of participatory multistakeholder engagement that informed the development of a new national tuberculosis (TB) policy in Georgia, and the lessons learnt. Guided by realist evaluation methods, a multistakeholder dialogue was organised to elicit stakeholders' assumptions on challenges and possible solutions for better TB control. Two participatory workshops were conducted with key actors, interspersed by reflection meetings within the research team and discussions with policymakers. Using concept mapping and causal mapping techniques, and drawing causal loop diagrams, we visualised how actors understood TB service provision challenges and the potential means by which a results-based financing (RBF) policy could address these. The study was conducted in Tbilisi, Georgia. A total of 64 key actors from the Ministry of Labour, Health and Social Affairs, staff of the Global Fund to Fight AIDS, TB and Malaria Georgia Project, the National Centre for Disease Control and Public Health, the National TB programme, TB service providers and members of the research team were involved in the workshops. Findings showed that beyond provider incentives, additional policy components were necessary. These included broadening the incentive package to include institutional and organisational incentives, retraining service providers, clear redistribution of roles to support an integrated care model, and refinement of monitoring tools. Health system elements, such as effective referral systems and health information systems were highlighted as necessary for service improvement. Developing policies that address complex issues requires methods that facilitate linkages between multiple stakeholders and between theory and practice. Such participatory approaches can be informed by realist evaluation principles and visually facilitated by causal loop diagrams. This approach allowed us leverage stakeholders' knowledge and expertise on TB service delivery and RBF to codesign a new policy. [Abstract copyright: © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.]