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Rakesh PS, Shannawaz M. Ensuring universal access to quality care for persons with presumed tuberculosis reaching the private sector: lessons from Kerala. Int J Equity Health 2024; 23:101. [PMID: 38760667 PMCID: PMC11102222 DOI: 10.1186/s12939-024-02151-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 03/15/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND More than half of the people with Tuberculosis (TB) symptoms in India seek care from the private sector. People with TB getting treatment from private sector in India are considered to be at a higher risk for receiving suboptimal quality of care in terms of incorrect diagnosis and treatment, lack of treatment adherence support with a high loss to follow-up rate that could eventually increase their risk of drug resistance. The current study aims at documenting the approach and efforts taken by the Kerala state to partner with the private health care delivery providers for ensuring quality TB care to the people with presumed TB reaching them. METHODS A case study approach was adopted with review of all available literature followed by five Key Informant Interviews to understand the case through a primary descriptive exploration. Grounded theory approach was used to generating the single theory of the case itself that explains it. RESULTS Kerala state has taken a variety of interventions to ensure universal access to TB care for citizens reaching the private sector with documented improvement in the quality of TB care. Key learnings from these initiatives were (i) patients need to be at the centre of partnerships, (ii) good governance is essential for ensuring Universal Health Coverage in a mixed health system, (iii) data intelligence is required to guide partnerships, (iv) identification of the correct 'problems' is crucial for effective design of partnerships and (v) a platform for meaningful dialogue of key stakeholders is needed. CONCLUSION Kerala experience demonstrated that if governments take a proactive role in engaging the private sector, in an informed and evidence-based way, they can leverage the advantages of the private sector while protecting the public health interest.
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Affiliation(s)
- P S Rakesh
- Amity Institute of Public Health & Hospital Administration, Amity University, Noida, India.
- The Union South East Asia Office, New Delhi, India.
| | - Mohd Shannawaz
- Amity Institute of Public Health & Hospital Administration, Amity University, Noida, India
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Jiang W, Dong D, Febriani E, Adeyi O, Fuady A, Surendran S, Tang S, Mutasa RU. Policy gaps in addressing market failures and intervention misalignments in tuberculosis control: prospects for improvement in China, India, and Indonesia. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 46:101045. [PMID: 38827933 PMCID: PMC11143451 DOI: 10.1016/j.lanwpc.2024.101045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 02/23/2024] [Accepted: 02/29/2024] [Indexed: 06/05/2024]
Abstract
India, Indonesia, and China are the top three countries with the highest tuberculosis (TB) burden. To achieve the end TB target, we analyzed policy gaps in addressing market failures as well as misalignments between National TB Programs (NTP) and health insurance policies in TB control in three countries. In India and Indonesia, we found insufficient incentives to engage private practitioners or to motivate them to improve service quality. In addition, ineffective supervision of practice and limited coverage of drugs or diagnostics was present in all three countries. The major policy misalignment identified in all three countries is that while treatment guidelines encourage outpatient treatment for drug-sensitive patients, the national health insurance scheme covers primarily inpatient services. We therefore advocate for better alignment of TB control programs and broader universal health coverage (UHC) programs to leverage additional resources from national health insurance programs to improve the effective coverage of TB care.
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Affiliation(s)
- Weixi Jiang
- School of Public Health, Fudan University, Xuhui District, Shanghai, China
| | - Di Dong
- Health, Nutrition and Population Global Practice, World Bank, Washington, DC 20433, USA
| | - Esty Febriani
- Lecturer of Public Health Magister Heath Institute, STIKKU, West Java, Indonesia
| | | | - Ahmad Fuady
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Sapna Surendran
- Health, Nutrition and Population Global Practice, World Bank, Washington, DC 20433, USA
| | - Shenglan Tang
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Ronald Upenyu Mutasa
- Health, Nutrition and Population Global Practice, World Bank, Washington, DC 20433, USA
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Jhaveri TA, Jhaveri D, Galivanche A, Lubeck-Schricker M, Voehler D, Chung M, Thekkur P, Chadha V, Nathavitharana R, Kumar AMV, Shewade HD, Powers K, Mayer KH, Haberer JE, Bain P, Pai M, Satyanarayana S, Subbaraman R. Barriers to engagement in the care cascade for tuberculosis disease in India: A systematic review of quantitative studies. PLoS Med 2024; 21:e1004409. [PMID: 38805509 PMCID: PMC11166313 DOI: 10.1371/journal.pmed.1004409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/11/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND India accounts for about one-quarter of people contracting tuberculosis (TB) disease annually and nearly one-third of TB deaths globally. Many Indians do not navigate all care cascade stages to receive TB treatment and achieve recurrence-free survival. Guided by a population/exposure/comparison/outcomes (PECO) framework, we report findings of a systematic review to identify factors contributing to unfavorable outcomes across each care cascade gap for TB disease in India. METHODS AND FINDINGS We defined care cascade gaps as comprising people with confirmed or presumptive TB who did not: start the TB diagnostic workup (Gap 1), complete the workup (Gap 2), start treatment (Gap 3), achieve treatment success (Gap 4), or achieve TB recurrence-free survival (Gap 5). Three systematic searches of PubMed, Embase, and Web of Science from January 1, 2000 to August 14, 2023 were conducted. We identified articles evaluating factors associated with unfavorable outcomes for each gap (reported as adjusted odds, relative risk, or hazard ratios) and, among people experiencing unfavorable outcomes, reasons for these outcomes (reported as proportions), with specific quality or risk of bias criteria for each gap. Findings were organized into person-, family-, and society-, or health system-related factors, using a social-ecological framework. Factors associated with unfavorable outcomes across multiple cascade stages included: male sex, older age, poverty-related factors, lower symptom severity or duration, undernutrition, alcohol use, smoking, and distrust of (or dissatisfaction with) health services. People previously treated for TB were more likely to seek care and engage in the diagnostic workup (Gaps 1 and 2) but more likely to suffer pretreatment loss to follow-up (Gap 3) and unfavorable treatment outcomes (Gap 4), especially those who were lost to follow-up during their prior treatment. For individual care cascade gaps, multiple studies highlighted lack of TB knowledge and structural barriers (e.g., transportation challenges) as contributing to lack of care-seeking for TB symptoms (Gap 1, 14 studies); lack of access to diagnostics (e.g., X-ray), non-identification of eligible people for testing, and failure of providers to communicate concern for TB as contributing to non-completion of the diagnostic workup (Gap 2, 17 studies); stigma, poor recording of patient contact information by providers, and early death from diagnostic delays as contributing to pretreatment loss to follow-up (Gap 3, 15 studies); and lack of TB knowledge, stigma, depression, and medication adverse effects as contributing to unfavorable treatment outcomes (Gap 4, 86 studies). Medication nonadherence contributed to unfavorable treatment outcomes (Gap 4) and TB recurrence (Gap 5, 14 studies). Limitations include lack of meta-analyses due to the heterogeneity of findings and limited generalizability to some Indian regions, given the country's diverse population. CONCLUSIONS This systematic review illuminates common patterns of risk that shape outcomes for Indians with TB, while highlighting knowledge gaps-particularly regarding TB care for children or in the private sector-to guide future research. Findings may inform targeting of support services to people with TB who have higher risk of poor outcomes and inform multicomponent interventions to close gaps in the care cascade.
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Affiliation(s)
- Tulip A. Jhaveri
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - Disha Jhaveri
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Amith Galivanche
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Maya Lubeck-Schricker
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Dominic Voehler
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Mei Chung
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, United States of America
| | - Pruthu Thekkur
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | | | - Ruvandhi Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ajay M. V. Kumar
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
- Department of Community Medicine, Yenepoya Medical College, Yenepoya (deemed to be university), Mangalore, India
| | - Hemant Deepak Shewade
- Division of Health Systems Research, ICMR-National Institute of Epidemiology, Chennai, India
| | - Katherine Powers
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Kenneth H. Mayer
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- The Fenway Institute, Boston, Massachusetts, United States of America
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Paul Bain
- Countway Library of Medicine, Boston, Massachusetts, United States of America
| | - Madhukar Pai
- Department of Global and Public Health and McGill International TB Centre, McGill University, Montreal, Canada
| | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Ramnath Subbaraman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, United States of America
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
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Farhat M, Cox H, Ghanem M, Denkinger CM, Rodrigues C, Abd El Aziz MS, Enkh-Amgalan H, Vambe D, Ugarte-Gil C, Furin J, Pai M. Drug-resistant tuberculosis: a persistent global health concern. Nat Rev Microbiol 2024:10.1038/s41579-024-01025-1. [PMID: 38519618 DOI: 10.1038/s41579-024-01025-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 03/25/2024]
Abstract
Drug-resistant tuberculosis (TB) is estimated to cause 13% of all antimicrobial resistance-attributable deaths worldwide and is driven by both ongoing resistance acquisition and person-to-person transmission. Poor outcomes are exacerbated by late diagnosis and inadequate access to effective treatment. Advances in rapid molecular testing have recently improved the diagnosis of TB and drug resistance. Next-generation sequencing of Mycobacterium tuberculosis has increased our understanding of genetic resistance mechanisms and can now detect mutations associated with resistance phenotypes. All-oral, shorter drug regimens that can achieve high cure rates of drug-resistant TB within 6-9 months are now available and recommended but have yet to be scaled to global clinical use. Promising regimens for the prevention of drug-resistant TB among high-risk contacts are supported by early clinical trial data but final results are pending. A person-centred approach is crucial in managing drug-resistant TB to reduce the risk of poor treatment outcomes, side effects, stigma and mental health burden associated with the diagnosis. In this Review, we describe current surveillance of drug-resistant TB and the causes, risk factors and determinants of drug resistance as well as the stigma and mental health considerations associated with it. We discuss recent advances in diagnostics and drug-susceptibility testing and outline the progress in developing better treatment and preventive therapies.
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Affiliation(s)
- Maha Farhat
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Helen Cox
- Institute of Infectious Disease and Molecular Medicine, Wellcome Centre for Infectious Disease Research and Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Marwan Ghanem
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Claudia M Denkinger
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research (DZIF), partner site Heidelberg University Hospital, Heidelberg, Germany
| | | | - Mirna S Abd El Aziz
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Debrah Vambe
- National TB Control Programme, Manzini, Eswatini
| | - Cesar Ugarte-Gil
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX, USA
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada.
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Thapa P, Narasimhan P, Beek K, Hall JJ, Jayasuriya R, Mukherjee PS, Sheokand S, Heitkamp P, Shukla P, Klinton JS, Yellappa V, Mudgal N, Pai M. Unlocking the potential of informal healthcare providers in tuberculosis care: insights from India. BMJ Glob Health 2024; 9:e015212. [PMID: 38413099 PMCID: PMC10900372 DOI: 10.1136/bmjgh-2024-015212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 02/11/2024] [Indexed: 02/29/2024] Open
Affiliation(s)
- Poshan Thapa
- School of Population and Global Health, McGill University, Montreal, Quebec, Canada
- TB-PPM Learning Network, McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Padmanesan Narasimhan
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Kristen Beek
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - John J Hall
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Rohan Jayasuriya
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Surbhi Sheokand
- TB-PPM Learning Network, McGill International TB Centre, McGill University, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Petra Heitkamp
- TB-PPM Learning Network, McGill International TB Centre, McGill University, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Joel Shyam Klinton
- TB-PPM Learning Network, McGill International TB Centre, McGill University, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Vijayshree Yellappa
- TB-PPM Learning Network, McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | | | - Madhukar Pai
- School of Population and Global Health, McGill University, Montreal, Quebec, Canada
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6
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Aljerian N, Alharbi A. Assessing Medical Emergency E-referral Request Acceptance Patterns and Trends: A Comprehensive Analysis of Secondary Data From the Kingdom of Saudi Arabia. Cureus 2024; 16:e53511. [PMID: 38314384 PMCID: PMC10838169 DOI: 10.7759/cureus.53511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 02/06/2024] Open
Abstract
Introduction Patient transfers in emergencies have been linked to reduced mortality rates and enhanced quality of care. The Saudi Medical Appointments and Referrals Centre (SMARC), an e-referral system in the Kingdom of Saudi Arabia (KSA) since 2019, plays a crucial role in ensuring quality and continuity of care. The findings of this study can provide valuable insights into the effectiveness of the e-referral system and identify potential areas for improvement in the management of emergency cases. Objective This study aims to examine e-referral patterns for emergency medical cases throughout all 13 administrative regions of KSA. Concurrently, it estimates the acceptance rate of medical emergency referrals and investigates associated factors among KSA hospitals. Methods This retrospective study utilized secondary data from the SMARC e-referral system, specifically focusing on medical emergency e-referral requests in the entire KSA during 2021. Descriptive univariate analyses were conducted to characterize the referral requests, followed by bivariate analyses to explore associations between factors and referral acceptance. Adjusted multiple logistic regression analyses were then performed to calculate adjusted odds ratios (ORs) and corresponding 95% confidence intervals, controlling for potential confounding variables. Results A total of 29,660 medical emergency referral requests were initiated across all regions of KSA during the study time frame, and, of these, 20,523 (69.19%) were accepted. The average age of patients with a medical emergency referral was 52 years old, and referral requests were higher among Saudis (13,781; 54.18%), males (13,781; 54.18%), and those from the Western region (10,560; 35.60%). Nearly 20,854 (70%) were due to the unavailability of specialized doctors or specialties in facilities. Based on multi-logistic regression, referral request acceptance was high in some factors as follows: compared to the Central region, requests from the Northern, Southern, Eastern, and Western regions had higher acceptance rates at 123%, 64%, 54%, and 46%, respectively. In addition, referral requests that were due to the unavailability of a specialized doctor or medical equipment had higher acceptance rates (19% and 16%), respectively, than those due to the unavailability of a specific specialty. Conclusion This study provides valuable insights into regional variations, sociodemographic factors, and referral reasons within the medical emergency e-referral system in the KSA. By estimating the acceptance rate of medical emergency referrals and investigating associated factors, this analysis confirms the effectiveness of the e-referral system in facilitating access to quality care, particularly for marginalized patients. The study highlights the need for health policy improvements to ensure equitable resource allocation and reduce disparities in healthcare access.
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Affiliation(s)
- Nawfal Aljerian
- Emergency Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Emergency Medicine, Medical Referrals Centre, Ministry of Health, Riyadh, SAU
| | - Abdullah Alharbi
- Family and Community Medicine, Faculty of Medicine, Jazan University, Jazan, SAU
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7
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Sassi A, Lestari BW, El Muna KUN, Oga-Omenka C, Afifah N, Widarna R, Huria L, Aguilera Vasquez N, Benedetti A, Hadisoemarto PF, Daniels B, Das J, Pai M, Alisjahbana B. Impact of the COVID-19 pandemic on quality of tuberculosis care in private facilities in Bandung, Indonesia: a repeated cross-sectional standardized patients study. BMC Public Health 2024; 24:102. [PMID: 38183023 PMCID: PMC10771004 DOI: 10.1186/s12889-023-17001-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/16/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Indonesia has the second highest incidence of tuberculosis in the world. While 74% of people with tuberculosis in Indonesia first accessed the private health sector when seeking care for their symptoms, only 18% of tuberculosis notifications originate in the private sector. Little is known about the impact of the COVID-19 pandemic on the private sector. Using unannounced standardized patient visits to private providers, we aimed to measure quality of tuberculosis care during the COVID-19 pandemic. METHODS A cross-sectional study was conducted using standardized patients in Bandung City, West Java, Indonesia. Ten standardized patients completed 292 visits with private providers between 9 July 2021 and 21 January 2022, wherein standardized patients presented a presumptive tuberculosis case. Results were compared to standardized patients surveys conducted in the same geographical area before the onset of COVID-19. RESULTS Overall, 35% (95% confidence interval (CI): 29.2-40.4%) of visits were managed correctly according to national tuberculosis guidelines. There were no significant differences in the clinical management of presumptive tuberculosis patients before and during the COVID-19 pandemic, apart from an increase in temperature checks (adjusted odds ratio (aOR): 8.05, 95% CI: 2.96-21.9, p < 0.001) and a decrease in throat examinations (aOR 0.16, 95% CI: 0.06-0.41, p = 0.002) conducted during the pandemic. CONCLUSIONS Results indicate that providers successfully identify tuberculosis in their patients yet do not manage them according to national guidelines. There were no major changes found in quality of tuberculosis care due to the COVID-19 pandemic. As tuberculosis notifications have declined in Indonesia due to the COVID-19 pandemic, there remains an urgent need to increase private provider engagement in Indonesia and improve quality of care.
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Affiliation(s)
- Angelina Sassi
- Department of Epidemiology, Biostatistics, and Occupational Health, and McGill International TB Centre, McGill University, Montreal, Canada
| | - Bony Wiem Lestari
- Research Center for Care and Control of Infectious Disease, Universitas Padjadjaran, Bandung, Indonesia
- Department of Public Health, Universitas Padjadjaran, Bandung, Indonesia
| | - Kuuni Ulfah Naila El Muna
- Research Center for Care and Control of Infectious Disease, Universitas Padjadjaran, Bandung, Indonesia
- Department of Public Health, Universitas Nahdlatul Ulama Surabaya, Surabaya, Indonesia
| | - Charity Oga-Omenka
- Department of Epidemiology, Biostatistics, and Occupational Health, and McGill International TB Centre, McGill University, Montreal, Canada
- School of Public Health Sciences, University of Waterloo, Waterloo, Canada
| | - Nur Afifah
- Research Center for Care and Control of Infectious Disease, Universitas Padjadjaran, Bandung, Indonesia
| | - Rodiah Widarna
- Research Center for Care and Control of Infectious Disease, Universitas Padjadjaran, Bandung, Indonesia
| | - Lavanya Huria
- Department of Epidemiology, Biostatistics, and Occupational Health, and McGill International TB Centre, McGill University, Montreal, Canada
| | - Nathaly Aguilera Vasquez
- Department of Epidemiology, Biostatistics, and Occupational Health, and McGill International TB Centre, McGill University, Montreal, Canada
| | - Andrea Benedetti
- Department of Epidemiology, Biostatistics, and Occupational Health, and McGill International TB Centre, McGill University, Montreal, Canada
- Department of Medicine, McGill University, Montreal, Canada
| | - Panji Fortuna Hadisoemarto
- Research Center for Care and Control of Infectious Disease, Universitas Padjadjaran, Bandung, Indonesia
- Department of Public Health, Universitas Padjadjaran, Bandung, Indonesia
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics, and Occupational Health, and McGill International TB Centre, McGill University, Montreal, Canada
| | - Bachti Alisjahbana
- Research Center for Care and Control of Infectious Disease, Universitas Padjadjaran, Bandung, Indonesia.
- Department of Internal Medicine, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia.
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Powell-Jackson T, King JJC, Makungu C, Quaife M, Goodman C. Management Practices and Quality of Care: Evidence from the Private Health Care Sector in Tanzania. ECONOMIC JOURNAL (LONDON, ENGLAND) 2024; 134:436-456. [PMID: 38077853 PMCID: PMC10702364 DOI: 10.1093/ej/uead075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/05/2023] [Indexed: 02/12/2024]
Abstract
We measure the adoption of management practices in over 220 private for-profit and non-profit health facilities in 64 districts across Tanzania and link these data to process quality-of-care metrics, assessed using undercover standardised patients and clinical observations. We find that better managed health facilities are more likely to provide correct treatment in accordance with national treatment guidelines, adhere to a checklist of essential questions and examinations, and comply with infection prevention and control practices. Moving from the 10th to the 90th percentile in the management practice score is associated with a 48% increase in correct treatment. We then leverage a large-scale field experiment of an internationally recognised management support intervention in which health facilities are assessed against comprehensive standards, given an individually tailored quality improvement plan and supported through training and mentoring visits. We find zero to small effects on management scores, suggesting that improving management practices in this setting may be challenging.
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Faust L, Naidoo P, Caceres-Cardenas G, Ugarte-Gil C, Muyoyeta M, Kerkhoff AD, Nagarajan K, Satyanarayana S, Rakotosamimanana N, Grandjean Lapierre S, Adejumo OA, Kuye J, Oga-Omenka C, Pai M, Subbaraman R. Improving measurement of tuberculosis care cascades to enhance people-centred care. THE LANCET. INFECTIOUS DISEASES 2023; 23:e547-e557. [PMID: 37652066 DOI: 10.1016/s1473-3099(23)00375-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/01/2023] [Accepted: 06/08/2023] [Indexed: 09/02/2023]
Abstract
Care cascades represent the proportion of people reaching milestones in care for a disease and are widely used to track progress towards global targets for HIV and other diseases. Despite recent progress in estimating care cascades for tuberculosis (TB) disease, they have not been routinely applied at national and subnational levels, representing a lost opportunity for public health impact. As researchers who have estimated TB care cascades in high-incidence countries (India, Madagascar, Nigeria, Peru, South Africa, and Zambia), we describe the utility of care cascades and identify measurement challenges, including the lack of population-based disease burden data and electronic data capture, the under-reporting of people with TB navigating fragmented and privatised health systems, the heterogeneity of TB tests, and the lack of post-treatment follow-up. We outline an agenda for rectifying these gaps and argue that improving care cascade measurement is crucial to enhancing people-centred care and achieving the End TB goals.
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Affiliation(s)
- Lena Faust
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, QC, Canada; McGill International TB Centre, Montréal, QC, Canada
| | - Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - César Ugarte-Gil
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru; School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru; TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Monde Muyoyeta
- Tuberculosis Department, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA
| | - Karikalan Nagarajan
- Department of Social and Behavioural Research, ICMR-National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France; South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | | | - Simon Grandjean Lapierre
- McGill International TB Centre, Montréal, QC, Canada; Mycobacteriology Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar; Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Microbiology, Infectious Diseases and Immunology, Université de Montréal, Montréal, QC, Canada
| | | | - Joseph Kuye
- National Tuberculosis and Leprosy Control Program, Abuja, Nigeria
| | - Charity Oga-Omenka
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, QC, Canada; McGill International TB Centre, Montréal, QC, Canada
| | - Ramnath Subbaraman
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, MA, USA; Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA, USA.
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Sudharsanan N, Pillai VS, Favaretti C, Jose J, Jose S, McConnell M, Ali MK. Clinician Adherence to Hypertension Screening and Care Guidelines. JAMA Netw Open 2023; 6:e2347164. [PMID: 38085546 PMCID: PMC10716733 DOI: 10.1001/jamanetworkopen.2023.47164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/21/2023] [Indexed: 12/18/2023] Open
Abstract
This quality improvement study assesses opportunistic blood pressure measurement, communication of blood pressure reading to adult patients, and recommendation for a follow-up visit at health care facilities in 2 major cities in India.
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Affiliation(s)
- Nikkil Sudharsanan
- Professorship of Behavioral Science for Disease Prevention and Health Care, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Vasanthi Subramonia Pillai
- Professorship of Behavioral Science for Disease Prevention and Health Care, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Caterina Favaretti
- Professorship of Behavioral Science for Disease Prevention and Health Care, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Jithin Jose
- LEAD at Krea University, Chennai, Tamil Nadu, India
| | - Sandra Jose
- LEAD at Krea University, Chennai, Tamil Nadu, India
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Cambridge, Massachusetts
| | - Mohammed K. Ali
- Emory Global Diabetes Research Center, Woodruff Health Sciences Center, Emory University, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia
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11
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Rai DK. Are we really reducing cost of tuberculosis treatment in private sector: A valuable insight from cost analysis of patient who spend more than 500 dollar (4 lakh rupees)? Indian J Tuberc 2023; 70:508-509. [PMID: 37968059 DOI: 10.1016/j.ijtb.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 03/10/2023] [Accepted: 03/16/2023] [Indexed: 11/17/2023]
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Saria V, Das V, Daniels B, Pai M, Das J. The family doctor: health, kin testing and primary care in Patna, India. Anthropol Med 2023; 30:246-261. [PMID: 37830500 DOI: 10.1080/13648470.2023.2255773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 08/09/2023] [Indexed: 10/14/2023]
Abstract
Private primary care providers are usually the first site where afflictions come under institutional view. In the context of poverty, the relationship between illness and care is more complex than a simple division of responsibilities between various actors-with care given by kin, and diagnosis and treatment being the purview of providers. Since patients would often visit the provider with family members, providers are attuned to the patients' web of kinship. Providers would take patients' kinship arrangements into account when prescribing diagnostic tests and treatments. This paper terms this aspect of the clinical encounter as 'kin testing' to refer to situations/clinical encounters when providers take into consideration that care provided by kin was conditional. 'Kin testing' allowed providers to manage the episode of illness that had brought the patient to the clinic by relying on clinical judgment rather than confirmed laboratory tests. Furthermore, since complaints of poor health also were an idiom to communicate kin neglect, providers had to also discern how to negotiate diagnoses and treatments. Kinship determined whether the afflicted bodies brought to the clinics were diagnosed, whether medicines reached the body, and adherence maintained. The providers' actions make visible the difference that kinship made in how health is imagined in the clinic and in standardized protocols. Focusing on primary care clinics in Patna, India, we contribute to research that shows that kinship determines care and management of illnesses at home by showing that relatedness of patients gets folded in the clinic by providers as well.
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Affiliation(s)
- Vaibhav Saria
- Department of Gender, Sexuality, and Women's Studies, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Benjamin Daniels
- International Public Health, Georgetown University, Washington, District of Columbia, USA
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA
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13
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Svadzian A, Daniels B, Sulis G, Das J, Daftary A, Kwan A, Das V, Das R, Pai M. Do private providers initiate anti-tuberculosis therapy on the basis of chest radiographs? A standardised patient study in urban India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 13:100152. [PMID: 37383564 PMCID: PMC10306035 DOI: 10.1016/j.lansea.2023.100152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 06/30/2023]
Abstract
Background The initiation of anti-tuberculosis treatment (ATT) based on results of WHO-approved microbiological diagnostics is an important marker of quality tuberculosis (TB) care. Evidence suggests that other diagnostic processes leading to treatment initiation may be preferred in high TB incidence settings. This study examines whether private providers start anti-TB therapy on the basis of chest radiography (CXR) and clinical examinations. Methods This study uses the standardized patient (SP) methodology to generate accurate and unbiased estimates of private sector, primary care provider practice when a patient presents a standardized TB case scenario with an abnormal CXR. Using multivariate log-binomial and linear regressions with standard errors clustered at the provider level, we analyzed 795 SP visits conducted over three data collection waves from 2014 to 2020 in two Indian cities. Data were inverse-probability-weighted based on the study sampling strategy, resulting in city-wave-representative results. Findings Amongst SPs who presented to a provider with an abnormal CXR, 25% (95% CI: 21-28%) visits resulted in ideal management, defined as the provider prescribing a microbiological test and not offering a concurrent prescription for a corticosteroid or antibiotic (including anti-TB medications). In contrast, 23% (95% CI: 19-26%) of 795 visits were prescribed anti-TB medications. Of 795 visits, 13% (95% CI: 10-16%) resulted in anti-TB treatment prescriptions/dispensation and an order for confirmatory microbiological testing. Interpretation One in five SPs presenting with abnormal CXR were prescribed ATT by private providers. This study contributes novel insights to empiric treatment prevalence based on CXR abnormality. Further work is needed to understand how providers make trade-offs between existing diagnostic practices, new technologies, profits, clinical outcomes, and the market dynamics with laboratories. Funding This study was funded by the Bill & Melinda Gates Foundation (grant OPP1091843), and the Knowledge for Change Program at The World Bank.
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Affiliation(s)
- Anita Svadzian
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
| | - Giorgia Sulis
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
- Centre for Policy Research, New Delhi, India
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, ON, Canada
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment, Research Unit, Durban, South Africa
| | - Ada Kwan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, USA
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
- Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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14
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Svadzian A, Daniels B, Sulis G, Das J, Daftary A, Kwan A, Das V, Das R, Pai M. Use of standardised patients to assess tuberculosis case management by private pharmacies in Patna, India: A repeat cross-sectional study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001898. [PMID: 37235550 DOI: 10.1371/journal.pgph.0001898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/18/2023] [Indexed: 05/28/2023]
Abstract
As the first point of care for many healthcare seekers, private pharmacies play an important role in tuberculosis (TB) care. However, previous studies in India have showed that private pharmacies commonly dispense symptomatic treatments and broad-spectrum antibiotics over-the-counter (OTC), rather than referring patients for TB testing. Such inappropriate management by pharmacies can delaye TB diagnosis. We assessed medical advice and OTC drug dispensing practices of pharmacists for standardized patients presenting with classic symptoms of pulmonary TB (case 1) and for those with sputum smear positive pulmonary TB (case 2), and examined how practices have changed over time in an urban Indian site. We examined how and whether private pharmacies improved practices for TB in 2019 compared to a baseline study conducted in 2015 in the city of Patna, using the same survey sampling techniques and study staff. The proportion of patient-pharmacist interactions that resulted in correct or ideal management, as well as the proportion of interactions resulting in antibiotic, quinolone, and corticosteroid are presented, with standard errors clustered at the provider level. To assess the difference in case management and the use of drugs across the two cases by round, a difference in difference (DiD) model was employed. A total of 936 SP interactions were completed over both rounds of survey. Our results indicate that across both rounds of data collection, 331 of 936 (35%; 95% CI: 32-38%) of interactions were correctly managed. At baseline, 215 of 500 (43%; 95% CI: 39-47%) of interactions were correctly managed whereas 116 of 436 (27%; 95% CI: 23-31%) were correctly managed in the second round of data collection. Ideal management, where in addition to a referral, patients were not prescribed any potentially harmful medications, was seen in 275 of 936 (29%; 95% CI: 27-32%) of interactions overall, with 194 of 500 (39%; 95% CI: 35-43%) of interactions at baseline and 81 of 436 (19%; 95% CI: 15-22%) in round 2. No private pharmacy dispensed anti-TB medications without a prescription. On average, the difference in correct case management between case 1 vs. case 2 dropped by 20 percent points from baseline to the second round of data collection. Similarly, ideal case management decreased by 26 percentage points between rounds. This is in contrast with the dispensation of medicines, which had the opposite effect between rounds; the difference in dispensation of quinolones between case 1 and case 2 increased by 14 percentage points, as did corticosteroids by 9 percentage points, antibiotics by 25 percentage points and medicines generally by 30 percentage points. Our standardised patient study provides valuable insights into how private pharmacies in an Indian city changed their management of patients with TB symptoms or with confirmed TB over a 5-year period. We saw that overall, private pharmacy performance has weakened over time. However, no OTC dispensation of anti-TB medications occurred in either survey round. As the first point of contact for many care seekers, continued and sustained efforts to engage with Indian private pharmacies should be prioritized.
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Affiliation(s)
- Anita Svadzian
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | | | - Giorgia Sulis
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jishnu Das
- Georgetown University, Washington, DC, United States of America
- Centre for Policy Research, New Delhi, India
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, Ontario, Canada
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Ada Kwan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
- Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Ali T, Singh U, Ohikhuai C, Panwal T, Adetiba T, Agbaje A, Olusola Faleye B, Shyam Klinton J, Oga-Omenka C, Tseja-Akinrin A, Heitkamp P. Partnering with the private laboratories to strengthen TB diagnostics in Nigeria. J Clin Tuberc Other Mycobact Dis 2023; 31:100369. [PMID: 37122613 PMCID: PMC10130621 DOI: 10.1016/j.jctube.2023.100369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Despite being curable and preventable, tuberculosis (TB) affected 10 million people worldwide in 2020. In the seven highest TB burden countries, private providers account for more than two-thirds of initial care seeking. Closing gaps and finding the "missing people" with TB requires engagement of the private sector for better diagnostics and treatment. This review explores the efforts of a public-private partnership to enhance TB diagnostics in Nigeria, covering logistics and the distribution of GeneXpert machines and other diagnostic tools. Over three years, the Nigerian "hub and spoke" model led to a 28-fold increase in referrals of people with presumed TB in private diagnostic facilities. Various stakeholders' perspectives are also included, providing insight into opportunities and challenges of working with the private sector in this effort. As countries tackle the setbacks brought by COVID-19 and move towards reaching the End TB targets, partnerships such as these can strengthen the foundations of health systems.
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Affiliation(s)
| | - Urvashi Singh
- TBPPM Learning Network, Montreal, Canada
- McGill International TB Center, Montreal, Canada
| | | | | | | | | | | | - Joel Shyam Klinton
- TBPPM Learning Network, Montreal, Canada
- McGill International TB Center, Montreal, Canada
- Corresponding author.
| | | | | | - Petra Heitkamp
- TBPPM Learning Network, Montreal, Canada
- McGill International TB Center, Montreal, Canada
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Divala TH, Corbett EL, Kandulu C, Moyo B, MacPherson P, Nliwasa M, French N, Sloan DJ, Chiume L, Ndaferankhande MJ, Chilanga S, Majiga ST, Odland JØ, Fielding KL. Trial-of-antibiotics to assist tuberculosis diagnosis in symptomatic adults in Malawi (ACT-TB study): a randomised controlled trial. Lancet Glob Health 2023; 11:e556-e565. [PMID: 36925176 PMCID: PMC10030459 DOI: 10.1016/s2214-109x(23)00052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/01/2023] [Accepted: 01/18/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND Clinical practice and diagnostic algorithms often assume that tuberculosis can be ruled out in mycobacteriology-negative individuals whose symptoms improve with a trial-of-antibiotics. We aimed to investigate diagnostic performance, clinical benefit, and antimicrobial resistance using a randomised controlled trial. METHODS In this three-arm, individually randomised, open-label, controlled trial, we enrolled Malawian adults (aged ≥18 years) attending primary care who reported being unwell for at least 14 days (including cough) with no immediate indication for hospitalisation at Limbe and Ndirande Health Centres in Blantyre. Participants were randomly allocated (1:1:1) to azithromycin (500 mg taken once per day for 3 days), amoxicillin (1 g taken three times per day for 5 days), or standard of care with no immediate antibiotics, stratified by study site. Sputum at enrolment and day 8 was tested for tuberculosis (microscopy, Xpert MTB/RIF, and culture). The primary efficacy outcome was day 8 specificity (percentage with symptom improvement among mycobacteriology-negative participants), and day 29 clinical outcome (death, hospitalisation, or missed tuberculosis diagnosis) among all randomised participants. This study is registered with ClinicalTrials.gov, NCT03545373. FINDINGS Between Feb 25, 2019, and March 14, 2020, 5825 adults were screened and 1583 (mean age 36 years; 236 [14·9%] HIV positive) were randomly assigned to standard of care (530 participants), azithromycin (527 participants), or amoxicillin (526 participants) groups. Overall, 6·3% (100 of 1583 participants) had positive baseline sputum mycobacteriology. 310 (79·1%) of 392 patients receiving standard of care reported symptom improvement at day 8, compared with 340 (88·7%) of 383 patients receiving azithromycin (adjusted difference 8·6%, 95% CI 3·9-13·3%; p<0·0004) and 346 (89·4%) of 387 receiving amoxicillin (adjusted difference 8·8%, 4·0-13·6%; p=0·0003). The proportion of participants with day 29 composite clinical outcomes was similar between groups (standard of care 1% [7 of 530 participants], azithromycin 1% [6 of 527 participants], amoxicillin 2% [12 of 526 participants]). INTERPRETATION Routine outpatient trial-of-antibiotics during tuberculosis investigations modestly improved diagnostic specificity for mycobacteriologically confirmed tuberculosis but had no appreciable effect on death, hospitalisation, and missed tuberculosis diagnosis. These results confirm the limited benefit of trial-of-antibiotics, presenting an opportunity for discontinuation of trial-of-antibiotics and improved antimicrobial stewardship during tuberculosis screening, without affecting clinical outcomes. FUNDING Northern Norway Regional Health Authority (Helse Nord RHF), Commonwealth Scholarship Commission in the UK, Wellcome Trust, UK Medical Research Council, and the UK Department for International Development.
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Affiliation(s)
- Titus H Divala
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; TB Centre, London School of Hygiene & Tropical Medicine, Bloomsbury, London, UK; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
| | - Elizabeth L Corbett
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; TB Centre, London School of Hygiene & Tropical Medicine, Bloomsbury, London, UK; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Chikondi Kandulu
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Brewster Moyo
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Peter MacPherson
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; TB Centre, London School of Hygiene & Tropical Medicine, Bloomsbury, London, UK; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK; School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Marriott Nliwasa
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; TB Centre, London School of Hygiene & Tropical Medicine, Bloomsbury, London, UK; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Neil French
- Institute of Infection Veterinary and Ecological Science, University of Liverpool, Liverpool, UK
| | - Derek J Sloan
- School of Medicine, University of St Andrews, Fife, Scotland, UK; Victoria Hospital, NHS Fife, Kirkcaldy, Scotland, UK
| | - Lingstone Chiume
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Sanderson Chilanga
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Sabina Tazirwa Majiga
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Jon Øyvind Odland
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Katherine L Fielding
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi; TB Centre, London School of Hygiene & Tropical Medicine, Bloomsbury, London, UK
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Daniels B, Shah D, Kwan AT, Das R, Das V, Puri V, Tipre P, Waghmare U, Gomare M, Keskar P, Das J, Pai M. Tuberculosis diagnosis and management in the public versus private sector: a standardised patients study in Mumbai, India. BMJ Glob Health 2022; 7:bmjgh-2022-009657. [PMID: 36261230 PMCID: PMC9582305 DOI: 10.1136/bmjgh-2022-009657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/13/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND There are few rigorous studies comparing quality of tuberculosis (TB) care in public versus private sectors. METHODS We used standardised patients (SPs) to measure technical quality and patient experience in a sample of private and public facilities in Mumbai. RESULTS SPs presented a 'classic, suspected TB' scenario and a 'recurrence or drug-resistance' scenario. In the private sector, SPs completed 643 interactions. In the public sector, 164 interactions. Outcomes included indicators of correct management, medication use and client experience. Public providers used microbiological testing (typically, microscopy) more frequently, in 123 of 164 (75%; 95% CI 68% to 81%) vs 223 of 644 interactions (35%; 95% CI 31% to 38%) in the private sector. Private providers were more likely to order chest X-rays, in 556 of 639 interactions (86%; 95% CI 84% to 89%). According to national TB guidelines, we found higher proportions of correct management in the public sector (75% vs 35%; (adjusted) difference 35 percentage points (pp); 95% CI 25 to 46). If X-rays were considered acceptable for the first case but drug-susceptibility testing was required for the second case, the private sector correctly managed a slightly higher proportion of interactions (67% vs 51%; adjusted difference 16 pp; 95% CI 7 to 25). Broad-spectrum antibiotics were used in 76% (95% CI 66% to 84%) of the interactions in public hospitals, and 61% (95% CI 58% to 65%) in private facilities. Costs in the private clinics averaged rupees INR 512 (95% CI 485 to 539); public facilities charged INR 10. Private providers spent more time with patients (4.4 min vs 2.4 min; adjusted difference 2.0 min; 95% CI 1.2 to 2.9) and asked a greater share of relevant questions (29% vs 43%; adjusted difference 13.7 pp; 95% CI 8.2 to 19.3). CONCLUSIONS While the public providers did a better job of adhering to national TB guidelines (especially microbiological testing) and offered less expensive care, private sector providers did better on client experience.
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Affiliation(s)
- Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA
| | - Daksha Shah
- Public Health Department, Municipal Corporation of Greater Mumbai, Mumbai, India
| | - Ada T Kwan
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Varsha Puri
- Public Health Department, Municipal Corporation of Greater Mumbai, Mumbai, India
| | - Pranita Tipre
- Public Health Department, Municipal Corporation of Greater Mumbai, Mumbai, India
| | - Upalimitra Waghmare
- Public Health Department, Municipal Corporation of Greater Mumbai, Mumbai, India
| | - Mangala Gomare
- Public Health Department, Municipal Corporation of Greater Mumbai, Mumbai, India
| | - Padmaja Keskar
- Public Health Department, Municipal Corporation of Greater Mumbai, Mumbai, India
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Québec, Canada
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18
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Zulu DW, Silumbwe A, Maritim P, Zulu JM. Integration of systematic screening for tuberculosis in outpatient departments of urban primary healthcare facilities in Zambia: a case study of Kitwe district. BMC Health Serv Res 2022; 22:732. [PMID: 35655301 PMCID: PMC9160503 DOI: 10.1186/s12913-022-08043-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Tuberculosis (TB) is the leading cause of death from a single infectious agent globally, killing about 1.5 million people annually, yet 3 million cases are missed every year. The World Health Organization recommends systematic screening of suspected active TB patients among those visiting the healthcare facilities. While many countries have scaled-up systematic screening of TB, there has been limited assessment of the extent of its integration into the health system. This study sought to explore factors that shape the integration of systematic screening of TB in outpatient departments of primary healthcare facilities in Kitwe district, Zambia.
Methods
This was a qualitative case study with health providers including district managers, TB focal point persons and laboratory personnel working in six purposively selected primary healthcare facilities. Data was collected through key informant (n = 8) and in-depth (n = 15) interviews. Data analysis was conducted using QDA Miner software and guided by Atun’s Integration framework.
Results
The facilitators to integration of systematic screening for TB into out patient departments of primary health facilities included the perceived high burden TB, compatibility of the systematic screening for TB program with healthcare workers training and working schedules, stakeholder knowledge of each others interest and values, regular performance management and integrated outreach of TB screening services. Constraining factors to integration of systematic screening for TB into outpatient departments included complexity of screening for TB in children, unbalanced incentivization mechanisms, ownership and legitimacy of the TB screening program, negative health worker attitudes, social cultural misconceptions of TB and societal stigma as well as the COVID-19 pandemic.
Conclusion
Systematic screening of TB is not fully integrated into the primary healthcare facilities in Zambia to capture all those suspected with active TB that make contact with the health system. Finding the missing TB cases will, therefore, require contextual adaptation of the systematic screening for TB program to local needs and capacities as well as strengthening the health system.
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Xu DR, Cai Y, Wang X, Chen Y, Gong W, Liao J, Zhou J, Zhou Z, Zhang N, Tang C, Mi B, Lu Y, Wang R, Zhao Q, He W, Liang H, Li J, Pan J. Improving Data Surveillance Resilience Beyond COVID-19: Experiences of Primary heAlth Care quAlity Cohort In ChinA (ACACIA) Using Unannounced Standardized Patients. Am J Public Health 2022; 112:913-922. [PMID: 35483014 PMCID: PMC9137008 DOI: 10.2105/ajph.2022.306779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2022] [Indexed: 12/02/2023]
Abstract
We analyzed COVID-19 influences on the design, implementation, and validity of assessing the quality of primary health care using unannounced standardized patients (USPs) in China. Because of the pandemic, we crowdsourced our funding, removed tuberculosis from the USP case roster, adjusted common cold and asthma cases, used hybrid online-offline training for USPs, shared USPs across provinces, and strengthened ethical considerations. With those changes, we were able to conduct fieldwork despite frequent COVID-19 interruptions. Furthermore, the USP assessment tool maintained high validity in the quality checklist (criteria), USP role fidelity, checklist completion, and physician detection of USPs. Our experiences suggest that the pandemic created not only barriers but also opportunities to innovate ways to build a resilient data collection system. To build data system reliance, we recommend harnessing the power of technology for a hybrid model of remote and in-person work, learning from the sharing economy to pool strengths and optimize resources, and dedicating individual and group leadership to problem-solving and results. (Am J Public Health. 2022;112(6):913-922. https://doi.org/10.2105/AJPH.2022.306779).
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Affiliation(s)
- Dong Roman Xu
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yiyuan Cai
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Xiaohui Wang
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yaolong Chen
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Wenjie Gong
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jing Liao
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jifang Zhou
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Zhongliang Zhou
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Nan Zhang
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Chengxiang Tang
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Baibing Mi
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yun Lu
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Ruixin Wang
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Qing Zhao
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Wenjun He
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Huijuan Liang
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jinghua Li
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jay Pan
- Dong (Roman) Xu is with SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital, Southern Medical University (SMU), Guangzhou, China. Yiyuan Cai is with the Department of Epidemiology and Health Statistics, School of Public Health, Guizhou Medical University, Guizhou, China. Xiaohui Wang is with the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China. Yaolong Chen is with the Institute of Health Data Science, Lanzhou University, Lanzhou, China. Wenjie Gong is with HER Team and the Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, China. Jing Liao and Jinghua Li are with the Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China. Jifang Zhou is with the School of International Business, China Pharmaceutical University, Nanjing, China. Zhongliang Zhou is with the School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China. Nan Zhang and Huijuan Liang are with the School of Health Management, Inner Mongolia Medical University, Hohhot, China. Chengxiang Tang is with the Macquarie University Centre for the Health Economy, Macquarie Business School, Macquarie University, Sydney, Australia. Baibing Mi is with the Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China. Yun Lu is with the Department of Preventive Medicine, Maternal and Child Health, School of Public Health, Guizhou Medical University, Guizhou, China. Ruixin Wang is with the Department of Health Economics, School of Public Health, Fudan University, Shanghai, China. Jay Pan is with HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
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Rao JS, Diwan V, Kumar AA, Varghese SS, Sharma U, Purohit M, Das A, Rodrigues R. Acceptability of video observed treatment vs. directly observed treatment for tuberculosis: a comparative analysis between South and Central India. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.17865.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Directly Observed Treatment (DOT) is a requirement in the management of Tuberculosis (TB) globally. With the transition from alternate day treatment to daily treatment in India, monitoring treatment adherence through DOT is a logistic challenge. The pervasiveness of mobile phones in India provides a unique opportunity to address this challenge remotely. This study was designed to compare the acceptability of mobile phones for antitubercular treatment (ATT) support in two distinct regions of India. Methodology This was a cross-sectional exploratory study that enrolled 351 patients with TB, of whom 185 were from Bangalore, South India, and 166 from Ujjain, Central India. Trained research assistants administered a pretested questionnaire comprising demographics, phone usage patterns, and acceptability of mobile phone technology to support treatment adherence to TB medicines. Results The mean age of the 351 participants was 32±13.6 years of whom 140 (40%) were women. Of the participants, 259 (74%) were urban, 221 (63%) had >4 years of education. A significantly greater number of participants were newly diagnosed with TB and were in the intensive phase of treatment. Overall, 218 (62%) preferred vDOT over DOT. There was an overall difference in preference between the two sites which is explained by differences in socio-economic variables. Conclusion Mobile phone adherence support is acceptable to patients on Antitubercular treatment ATT with minor variations in design based on demographic and cultural differences. In India, the preference for voice calls over text messages/SMS while designing mHealth interventions cannot be ignored. Of importance is the preference for DOT over vDOT in central India, unlike South India. However, in time, the expanding use of mobile technology supplemented with counseling, could overcome the barriers of privacy and stigma and promote the transition from in-person DOT to vDOT or mobile phone adherence monitoring and support for ATT in India.
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21
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Kovacs RJ, Lagarde M, Cairns J. Can patients improve the quality of care they receive? Experimental evidence from Senegal. WORLD DEVELOPMENT 2022; 150:105740. [PMID: 35115735 PMCID: PMC8651629 DOI: 10.1016/j.worlddev.2021.105740] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 06/14/2023]
Abstract
Providers in many low and middle-income countries (LMICs) often fail to correctly diagnose and treat their patients, even though they have the clinical knowledge to do so. Against the backdrop of many failed attempts to increase provider effort, this study examines whether quality of care can be improved by encouraging patients to be more active during consultations. We design a simple experiment with undercover standardised patients who randomly vary how much information they disclose about their symptoms. We find that providers are 27% more likely to correctly manage a patient who volunteers several key symptoms of their condition at the start of the consultation, compared to a typical patient who shares less information. Lower performance in the control group is not due to providers' lack of knowledge, an incapacity to ask the right questions, or a response to time or resource constraints. Instead, providers' low motivation seems to limit their ability to adapt their effort to patients' inputs in the consultation. Our findings provide proof-of-concept evidence that interventions making patients more active in their consultations could significantly improve the quality of care in LMICs.
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Affiliation(s)
- Roxanne J. Kovacs
- Department of Economics and Centre for Health Governance, University of Gothenburg, Sweden
| | - Mylene Lagarde
- London School of Economics and Political Science, Department of Health Policy, United Kingdom
| | - John Cairns
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, United Kingdom
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22
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Salomon A, Boffa J, Moyo S, Chikovore J, Sulis G, Daniels B, Kwan A, Mkhombo T, Wu S, Pai M, Daftary A. Prescribing practices for presumptive TB among private general practitioners in South Africa: a cross-sectional, standardised patient study. BMJ Glob Health 2022; 7:bmjgh-2021-007456. [PMID: 35042710 PMCID: PMC8768922 DOI: 10.1136/bmjgh-2021-007456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/22/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Medicine prescribing practices are integral to quality of care for leading infectious diseases such as tuberculosis (TB). We describe prescribing practices in South Africa’s private health sector, where an estimated third of people with TB symptoms first seek care. Methods Sixteen standardised patients (SPs) presented one of three cases during unannounced visits to private general practitioners (GPs) in Durban and Cape Town: TB symptoms, HIV-positive; TB symptoms, a positive molecular test for TB, HIV-negative; and TB symptoms, history of incomplete TB treatment, HIV-positive. Prescribing practices were recorded in standardised exit interviews and analysed based on their potential to contribute to negative outcomes, including increased healthcare expenditures, antibiotic overuse or misuse, and TB diagnostic delay. Factors associated with antibiotic use were assessed using Poisson regression with a robust variance estimator. Results Between August 2018 and July 2019, 511 SP visits were completed with 212 GPs. In 88.5% (95% CI 85.2% to 91.1%) of visits, at least one medicine (median 3) was dispensed or prescribed and most (93%) were directly dispensed. Antibiotics, which can contribute to TB diagnostic delay, were the most common medicine (76.5%, 95% CI 71.7% to 80.7% of all visits). A majority (86.1%, 95% CI 82.9% to 88.5%) belonged to the WHO Access group; fluoroquinolones made up 8.8% (95% CI 6.3% to 12.3%). Factors associated with antibiotic use included if the SP was asked to follow-up if symptoms persisted (RR 1.14, 95% CI 1.04 to 1.25) and if the SP presented as HIV-positive (RR 1.11, 95% CI 1.01 to 1.23). An injection was offered in 31.9% (95% CI 27.0% to 37.2%) of visits; 92% were unexplained. Most (61.8%, 95% CI 60.2% to 63.3%) medicines were not listed on the South African Primary Healthcare Essential Medicines List. Conclusion Prescribing practices among private GPs for persons presenting with TB-like symptoms in South Africa raise concern about inappropriate antimicrobial use, private healthcare costs and TB diagnostic delay.
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Affiliation(s)
- Angela Salomon
- School of Medicine, Queen's University, Kingston, Ontario, Canada
- McGill International TB Centre, McGill University, Montréal, Quebec, Canada
| | - Jody Boffa
- Division of Biostatistics and Epidemiology, Stellenbosch University, Stellenbosch, South Africa
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Sizulu Moyo
- Human and Social Capabilities Programme, Human Sciences Research Council, Cape Town, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Jeremiah Chikovore
- Human and Social Capabilities Programme, Human Sciences Research Council, Cape Town, South Africa
| | - Giorgia Sulis
- McGill International TB Centre, McGill University, Montréal, Quebec, Canada
- School of Population and Global Health, McGill University, Montreal, Québec, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
| | - Ada Kwan
- Division of Pulmonary and Critical Care Medicine, University of California School of Medicine, San Francisco, California, USA
| | - Tsatsawani Mkhombo
- Human and Social Capabilities Programme, Human Sciences Research Council, Durban, South Africa
| | - Sarah Wu
- Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montréal, Quebec, Canada
- School of Population and Global Health, McGill University, Montreal, Québec, Canada
| | - Amrita Daftary
- School of Global Health & Dahdaleh Institute of Global Health Research, York University, Toronto, Ontario, Canada
- Centre for the AIDS Programme of Research, Durban, KwaZulu-Natal, South Africa
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23
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Sudharsanan N, Wetzel S, Nachtnebel M, Loun C, Phy M, Kol H, Bärnighausen T. Know-do gaps for cardiovascular disease care in Cambodia: Evidence on clinician knowledge and delivery of evidence-based prevention actions. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000862. [PMID: 36962790 PMCID: PMC10022025 DOI: 10.1371/journal.pgph.0000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/11/2022] [Indexed: 11/18/2022]
Abstract
Cardiovascular diseases (CVD) are the leading cause of death in Cambodia. However, it is unknown whether clinicians in Cambodia provide evidence-based CVD preventive care actions. We address this important gap and provide one of the first assessments of clinical care for CVD prevention in an LMIC context. We determined the proportion of primary care visits by adult patients that resulted in evidence-based CVD preventive care actions, identified which care actions were most frequently missed, and estimated the know-do gap for each clinical action. We used data on 190 direct clinician-patient observations and 337 clinician responses to patient vignettes from 114 public primary care health facilities. Our main outcomes were the proportion of patient consultations and responses to care vignettes where clinicians measured blood pressure, blood glucose, body mass index, and asked questions regarding alcohol, tobacco, physical activity, and diet. There were very large clinical care shortfalls for all CVD care actions. Just 6.4% (95% CI: 3.0%, 13.0%) of patients had their BMI measured, 8.0% (4.6%, 13.6%) their blood pressure measured at least twice, only 4.7% (1.9%, 11.2%) their blood glucose measured. Less than 21% of patients were asked about their physical activity (11.7% [7.0%, 18.9%]), smoking (18.0% [11.8%, 26.5%]), and alcohol-related behaviors (20.2% [13.7%, 28.9%]). We observed the largest know-do gaps for blood glucose and BMI measurements with smaller but important know-do gaps for the other clinical actions. CVD care did not vary across clinician cadre or by years of experience. We find large CVD care delivery gaps in primary-care facilities across Cambodia. Our results suggest that diabetes is being substantially underdiagnosed and that clinicians are losing CVD prevention potential by not identifying individuals who would benefit from behavioral changes. The large overall and know-do gaps suggest that interventions for improving preventive care need to target both clinical knowledge and the bottlenecks between knowledge and care behavior.
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Affiliation(s)
- Nikkil Sudharsanan
- Professorship of Behavioral Science for Disease Prevention and Health Care, Technical University of Munich, Munich, Germany
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Sarah Wetzel
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | | | - Chhun Loun
- Department of Preventive Medicine, Ministry of Health, Phnom Penh, Cambodia
| | - Maly Phy
- Department of Preventive Medicine, Ministry of Health, Phnom Penh, Cambodia
| | - Hero Kol
- Department of Preventive Medicine, Ministry of Health, Phnom Penh, Cambodia
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
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Rosapep LA, Faye S, Johns B, Olusola-Faleye B, Baruwa EM, Sorum MK, Nwagagbo F, Adamu AA, Kwan A, Obanubi C, Atobatele AO. Tuberculosis care quality in urban Nigeria: A cross-sectional study of adherence to screening and treatment initiation guidelines in multi-cadre networks of private health service providers. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000150. [PMID: 36962145 PMCID: PMC10021846 DOI: 10.1371/journal.pgph.0000150] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/07/2021] [Indexed: 11/19/2022]
Abstract
Nigeria has a high burden of tuberculosis (TB) and low case detection rates. Nigeria's large private health sector footprint represents an untapped resource for combating the disease. To examine the quality of private sector contributions to TB, the USAID-funded Sustaining Health Outcomes through the Private Sector (SHOPS) Plus program evaluated adherence to national standards for management of presumptive and confirmed TB among the clinical facilities, laboratories, pharmacies, and drug shops it trained to deliver TB services. The study used a standardized patient (SP) survey methodology to measure case management protocol adherence among 837 private and 206 public providers in urban Lagos and Kano. It examined two different scenarios: a "textbook" case of presumptive TB and a treatment initiation case where SPs presented as referred patients with confirmed TB diagnoses. Private sector results were benchmarked against public sector results. A bottleneck analysis examined protocol adherence departures at key points along the case management sequence that providers were trained to follow. Except for laboratories, few providers met the criteria for fully correct management of presumptive TB, though more than 70% of providers correctly engaged in TB screening. In the treatment initiation case 18% of clinical providers demonstrated fully correct case management. Private and public providers' adherence was not significantly different. Bottleneck analysis revealed that the most common deviations from correct management were failure to initiate sputum collection for presumptive patients and failure to conduct sufficiently thorough treatment initiation counseling for confirmed patients. This study found the quality of private providers' TB case management to be comparable to public providers in Nigeria, as well as to providers in other high burden countries. Findings support continued efforts to include private providers in Nigeria's national TB program. Though most providers fell short of desired quality, the bottleneck analysis points to specific issues that TB stakeholders can feasibly address with system- and provider-level interventions.
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Affiliation(s)
- Lauren A Rosapep
- Abt Associates Inc., International Development Division, Rockville, MD, United States of America
| | - Sophie Faye
- Abt Associates Inc., International Development Division, Rockville, MD, United States of America
| | - Benjamin Johns
- Abt Associates Inc., International Development Division, Rockville, MD, United States of America
| | - Bolanle Olusola-Faleye
- Abt Associates Inc., Sustaining Health Outcomes through the Private Sector (SHOPS) Plus Project, Lagos, Nigeria
| | - Elaine M Baruwa
- Abt Associates Inc., International Development Division, Rockville, MD, United States of America
| | - Micah K Sorum
- Abt Associates Inc., International Development Division, Rockville, MD, United States of America
| | - Flora Nwagagbo
- Abt Associates Inc., Sustaining Health Outcomes through the Private Sector (SHOPS) Plus Project, Lagos, Nigeria
| | - Abdu A Adamu
- Abt Associates Inc., Sustaining Health Outcomes through the Private Sector (SHOPS) Plus Project, Kano, Nigeria
| | - Ada Kwan
- Division of Pulmonary and Critical Care, University of California San Francisco, San Francisco, CA, United States of America
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, CA, United States of America
| | - Christopher Obanubi
- Division of Pulmonary and Critical Care, University of California San Francisco, San Francisco, CA, United States of America
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Ps R, Balakrishnan S, Ramachandran R, Nandhan S, Samuel NI, Pp P, Aloysius S. Using a Pharmacy-Based Surveillance System to Improve Standards for TB Care in Kerala, India. GLOBAL HEALTH: SCIENCE AND PRACTICE 2021; 9:846-854. [PMID: 34933980 PMCID: PMC8691886 DOI: 10.9745/ghsp-d-21-00346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/14/2021] [Indexed: 11/15/2022]
Abstract
A pharmacy-based surveillance system in Kerala, India, has helped to improve TB patient notifications from the private sector, build better public-private partnerships, and improve the quality of TB diagnosis. Pharmacy-based surveillance has the potential to strengthen TB surveillance and facilitate standards of TB care. Introduction: Eleven anti-TB drugs were included in the Government of India's Schedule H1 drug regulations in 2014. The National Strategic Plan for TB Elimination in India 2017–2025 recognized the opportunity to strengthen the TB surveillance system and improve the quality of TB care by implementing the Schedule H1 regulation. However, there were no documented systematic large-scale efforts to use Schedule H1 regulation to support TB surveillance or improve the quality of care. We aimed to document the process of implementation of the Schedule H1 regulation to enhance the quality of TB care and strengthen the TB surveillance system in Kerala, India. Methods: We conducted 33 in-depth interviews of the drugs control department enforcement officers, chemist shop owners, private-sector doctors, leaders of professional medical associations, and program managers and key staff of the TB Elimination Program in Kerala. Major themes identified were the process of implementation of Schedule H1 and how the National TB Elimination Program used the information. Findings from the qualitative interviews were corroborated with the quantitative information from the annual program performance reports and anti-TB drug sales data. Results: The TB Elimination Program of Kerala used the information from the Schedule H1 drug register to identify the missing TB cases and strengthen TB notification, identify providers for engagement and extend support to them for ensuring standards of TB care, and provide feedback to providers regarding prescription practices. Stakeholders felt that implementation of Schedule H1 surveillance has helped to improve TB patient notifications from the private sector, build better public-private partnerships, and improve the quality of TB diagnosis and treatment in Kerala. Conclusion: Pharmacy-based drug sales data collected either through regulatory or non-regulatory methods have immense potential to support TB elimination programs.
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Affiliation(s)
- Rakesh Ps
- World Health Organization National TB Elimination Program Technical Support Network, State TB Cell, Thiruvananthapuram, India.
| | - Shibu Balakrishnan
- World Health Organization National TB Elimination Program Technical Support Network, State TB Cell, Thiruvananthapuram, India
| | | | | | | | - Pramodkumar Pp
- District TB Center, Kerala State Health Services, Kerala, India
| | - Suja Aloysius
- District TB Center, Kerala State Health Services, Kerala, India
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26
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Pineda-Antunez C, Contreras-Loya D, Rodriguez-Atristain A, Opuni M, Bautista-Arredondo S. Characterizing health care provider knowledge: Evidence from HIV services in Kenya, Rwanda, South Africa, and Zambia. PLoS One 2021; 16:e0260571. [PMID: 34855816 PMCID: PMC8638969 DOI: 10.1371/journal.pone.0260571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 11/12/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Identifying approaches to improve levels of health care provider knowledge in resource-poor settings is critical. We assessed level of provider knowledge for HIV testing and counseling (HTC), prevention of mother-to-child transmission (PMTCT), and voluntary medical male circumcision (VMMC). We also explored the association between HTC, PMTCT, and VMMC provider knowledge and provider and facility characteristics. METHODS We used data collected in 2012 and 2013. Vignettes were administered to physicians, nurses, and counselors in facilities in Kenya (66), Rwanda (67), South Africa (57), and Zambia (58). The analytic sample consisted of providers of HTC (755), PMTCT (709), and VMMC (332). HTC, PMTCT, and VMMC provider knowledge scores were constructed using item response theory (IRT). We used GLM regressions to examine associations between provider knowledge and provider and facility characteristics focusing on average patient load, provider years in position, provider working in another facility, senior staff in facility, program age, proportion of intervention exclusive staff, person-days of training in facility, and management score. We estimated three models: Model 1 estimated standard errors without clustering, Model 2 estimated robust standard errors, and Model 3 estimated standard errors clustering by facility. RESULTS The mean knowledge score was 36 for all three interventions. In Model 1, we found that provider knowledge scores were higher among providers in facilities with senior staff and among providers in facilities with higher proportions of intervention exclusive staff. We also found negative relationships between the outcome and provider years in position, average program age, provider working in another facility, person-days of training, and management score. In Model 3, only the coefficients for provider years in position, average program age, and management score remained statistically significant at conventional levels. CONCLUSIONS HTC, PMTCT, and VMMC provider knowledge was low in Kenya, Rwanda, South Africa, and Zambia. Our study suggests that unobservable organizational factors may facilitate communication, learning, and knowledge. On the one hand, our study shows that the presence of senior staff and staff dedication may enable knowledge acquisition. On the other hand, our study provides a note of caution on the potential knowledge depreciation correlated with the time staff spend in a position and program age.
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Affiliation(s)
- Carlos Pineda-Antunez
- National Institute of Public Health (INSP), Division of Health Economics and Health Systems Innovations, Cuernavaca, Mexico
| | - David Contreras-Loya
- School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Alejandra Rodriguez-Atristain
- National Institute of Public Health (INSP), Division of Health Economics and Health Systems Innovations, Cuernavaca, Mexico
| | | | - Sergio Bautista-Arredondo
- National Institute of Public Health (INSP), Division of Health Economics and Health Systems Innovations, Cuernavaca, Mexico
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Alharbi AA, Alqassim AY, Muaddi MA, Alghamdi SS. Regional Differences in COVID-19 Mortality Rates in the Kingdom of Saudi Arabia: A Simulation of the New Model of Care. Cureus 2021; 13:e20797. [PMID: 34987945 PMCID: PMC8716006 DOI: 10.7759/cureus.20797] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2021] [Indexed: 12/23/2022] Open
Abstract
Background This study aimed to assess regional COVID-19 mortality rates and compare the five proposed business units (BUs). Methods A cross-sectional study was conducted in the Ministry of Health (MOH) hospitals in the Kingdom of Saudi Arabia (KSA). We included 1743 adults (≥ 18 years of age) with COVID-19 admitted to any of 30 MOH hospitals. Results The inpatients had confirmed mild to severe COVID-19 between March and mid-July 2020. The central BU (Riyadh) was used as the reference. MOH electronic health record data were reviewed and utilized, including variables reflecting hospital course (mortality and discharge status). The primary outcome was COVID-19-related inpatient death. Covariates included patient demographics, pre-existing chronic diseases, and COVID-19-related complications. The data were analysed using univariate and multivariate logistic regression. KSA inpatient mortality was 30%. Univariate and multivariate logistic regression analysis suggested that COVID-19-related mortality was significantly higher in the northern and western BUs and significantly lower in the southern and eastern BUs than in the central BU. On controlling for other variables, adjusted odds ratios (AORs) for essential COVID-19 mortality predictors during admission, using the central BU as a reference, were as 9.90 [95% CI, 4.53-21.61] and 1.55 [95% CI, 1.04-2.13] times higher in the northern and western BUs, respectively, and 0.60 [95% CI, 0.36-0.99] and 0.23 [95% CI, 0.14-0.038] times lower in the southern and eastern BUs, respectively. Conclusion The five BUs differed in COVID-19 mortality rates after adjusting for patient and disease characteristics, with the differences consistent with those in the regions comprising the BUs. These outcome differences apparently relate to differences in healthcare resources and quality.
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Affiliation(s)
- Abdullah A Alharbi
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan, SAU
| | - Ahmad Y Alqassim
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan, SAU
| | - Mohammed A Muaddi
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan, SAU
| | - Saleh S Alghamdi
- Clinical Audit General Directorate, Ministry of Health, Riyadh, SAU
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Das V, Daniels B, Kwan A, Saria V, Das R, Pai M, Das J. Simulated patients and their reality: An inquiry into theory and method. Soc Sci Med 2021; 300:114571. [PMID: 34865913 PMCID: PMC9077327 DOI: 10.1016/j.socscimed.2021.114571] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 11/02/2021] [Accepted: 11/15/2021] [Indexed: 11/25/2022]
Abstract
Simulated standardized patients (SSP) have emerged as close to a ‘gold standard’ for measuring the quality of clinical care. This method resolves problems of patient mix across healthcare providers and allows care to be benchmarked against preexisting standards. Nevertheless, SSPs are not real patients. How, then, should data from SSPs be considered relative to clinical observations with ‘real’ patients in a given health system? Here, we reject the proposition that SSPs are direct substitutes for real patients and that the validity of SSP studies therefore relies on their ability to imitate real patients. Instead, we argue that the success of the SSP methodology lies in its counterfactual manipulations of the possibilities available to real careseekers – especially those paths not taken up by them – through which real responses can be elicited from real providers. Using results from a unique pilot study where SSPs returned to providers for follow-ups when asked, we demonstrate that the SSP method works well to elicit responses from the provider through conditional manipulations of SSP behavior. At the same time, observational methods are better suited to understand what choices real people make, and how these can affect the direction of diagnosis and treatment. A combination of SSP and observational methods can thus help parse out how quality of care emerges for the “patient” as a shared history between care-seeking individuals and care providers. We assess how simulated standardized patients (SSPs) compare to ‘real’ patients. SSPs elicit real responses from providers for different counterfactual patients. However, SSPs are not informative of observed variation in patient behavior. SSPs illustrate how providers behave with different types of patients. Observation studies can complement SSPs by studying patient responses.
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Affiliation(s)
- Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, USA.
| | | | - Ada Kwan
- Department of Medicine, University of California at San Francisco, San Francisco, USA
| | - Vaibhav Saria
- Department of Gender, Sexuality, and Women's Studies, Simon Fraser University, Burnaby, Canada
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Canada; Manipal McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, India
| | - Jishnu Das
- Georgetown University, Washington DC, USA; Center for Policy Research, New Delhi, India
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Zawahir S, Le H, Nguyen TA, Beardsley J, Duc AD, Bernays S, Viney K, Cao Hung T, McKinn S, Tran HH, Nguyen Tu S, Velen K, Luong Minh T, Tran Thi Mai H, Nguyen Viet N, Nguyen Viet H, Nguyen Thi Cam V, Nguyen Trung T, Jan S, Marais BJ, Negin J, Marks GB, Fox G. Standardised patient study to assess tuberculosis case detection within the private pharmacy sector in Vietnam. BMJ Glob Health 2021; 6:bmjgh-2021-006475. [PMID: 34615661 PMCID: PMC8496389 DOI: 10.1136/bmjgh-2021-006475] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/17/2021] [Indexed: 11/25/2022] Open
Abstract
Background Of the estimated 10 million people affected by (TB) each year, one-third are never diagnosed. Delayed case detection within the private healthcare sector has been identified as a particular problem in some settings, leading to considerable morbidity, mortality and community transmission. Using unannounced standardised patient (SP) visits to the pharmacies, we aimed to evaluate the performance of private pharmacies in the detection and treatment of TB. Methods A cross-sectional study was undertaken at randomly selected private pharmacies within 40 districts of Vietnam. Trained actors implemented two standardised clinical scenarios of presumptive TB and presumptive multidrug-resistant TB (MDR-TB). Outcomes were the proportion of SPs referred for medical assessment and the proportion inappropriately receiving broad-spectrum antibiotics. Logistic regression evaluated predictors of SPs’ referral. Results In total, 638 SP encounters were conducted, of which only 155 (24.3%) were referred for medical assessment; 511 (80·1%) were inappropriately offered antibiotics. A higher proportion of SPs were referred without having been given antibiotics if they had presumptive MDR-TB (68/320, 21.3%) versus presumptive TB (17/318, 5.3%; adjusted OR=4.8, 95% CI 2.9 to 7.8). Pharmacies offered antibiotics without a prescription to 89.9% of SPs with presumptive TB and 70.3% with presumptive MDR-TB, with no clear follow-up plan. Conclusions Few SPs with presumptive TB were appropriately referred for medical assessment by private pharmacies. Interventions to improve appropriate TB referral within the private pharmacy sector are urgently required to reduce the number of undiagnosed TB cases in Vietnam and similar high-prevalence settings.
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Affiliation(s)
- Shukry Zawahir
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Hien Le
- Woolcock Institute of Medical Research, Kim Ma, Hanoi, Vietnam
| | - Thu Anh Nguyen
- Woolcock Institute of Medical Research, Kim Ma, Hanoi, Vietnam
| | - Justin Beardsley
- The Marie Bashir Institute, Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Anh Dang Duc
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
| | - Sarah Bernays
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Kerri Viney
- Centre of Global Health, Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden.,Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Thai Cao Hung
- Medical Service Administration, Government of Viet Nam Ministry of Health, Hanoi, Vietnam
| | - Shannon McKinn
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Hoang Huy Tran
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
| | - Son Nguyen Tu
- Clinical Pharmacy, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - Kavindhran Velen
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Tan Luong Minh
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
| | | | | | - Ha Nguyen Viet
- Woolcock Institute of Medical Research, Kim Ma, Hanoi, Vietnam
| | | | | | - Stephen Jan
- The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Ben J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity and the Children's Hospital at Westmead, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Joel Negin
- Faculty of Medicne and Health, The University of Sydney School of Public Health, Sydney, New South Wales, Australia
| | - Guy B Marks
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Woolcock Institute of Medical Research, Glebe, New South Wales, Australia
| | - Gregory Fox
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Arinaminpathy N, Nandi A, Vijayan S, Jha N, Nair SA, Kumta S, Dewan P, Rade K, Vadera B, Rao R, Sachdeva KS. Engaging with the private healthcare sector for the control of tuberculosis in India: cost and cost-effectiveness. BMJ Glob Health 2021; 6:bmjgh-2021-006114. [PMID: 34610905 PMCID: PMC8493898 DOI: 10.1136/bmjgh-2021-006114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/15/2021] [Indexed: 11/25/2022] Open
Abstract
Background The control of tuberculosis (TB) in India is complicated by the presence of a large, disorganised private sector where most patients first seek care. Following pilots in Mumbai and Patna (two major cities in India), an initiative known as the ‘Public–Private Interface Agency’ (PPIA) is now being expanded across the country. We aimed to estimate the cost-effectiveness of scaling up PPIA operations, in line with India’s National Strategic Plan for TB control. Methods Focusing on Mumbai and Patna, we collected cost data from implementing organisations in both cities and combined this data with models of TB transmission dynamics. Estimating the cost per disability adjusted life years (DALY) averted between 2014 (the start of PPIA scale-up) and 2025, we assessed cost-effectiveness using two willingness-to-pay approaches: a WHO-CHOICE threshold based on per-capita economic productivity, and a more stringent threshold incorporating opportunity costs in the health system. Findings A PPIA scaled up to ultimately reach 50% of privately treated TB patients in Mumbai and Patna would cost, respectively, US$228 (95% uncertainty interval (UI): 159 to 320) per DALY averted and US$564 (95% uncertainty interval (UI): 409 to 775) per DALY averted. In Mumbai, the PPIA would be cost-effective relative to all thresholds considered. In Patna, if focusing on adherence support, rather than on improved diagnosis, the PPIA would be cost-effective relative to all thresholds considered. These differences between sites arise from variations in the burden of drug resistance: among the services of a PPIA, improved diagnosis (including rapid tests with genotypic drug sensitivity testing) has greatest value in settings such as Mumbai, with a high burden of drug-resistant TB. Conclusions To accelerate decline in TB incidence, it is critical first to engage effectively with the private sector in India. Mechanisms such as the PPIA offer cost-effective ways of doing so, particularly when tailored to local settings.
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Affiliation(s)
- Nimalan Arinaminpathy
- Department of Infectious Disease Epidemiology, Imperial College London, London, London, UK
| | - Arindam Nandi
- Population Council, New York, New York, USA.,CDDEP, Washington, District of Columbia, USA
| | | | - Nita Jha
- World Health Partners, Patna, India
| | | | - Sameer Kumta
- Bill and Melinda Gates Foundation, India Country Office, New Delhi, India
| | - Puneet Dewan
- Bill and Melinda Gates Foundation, Seattle, Washington, USA
| | - Kiran Rade
- World Health Organization Country Office for India, New Delhi, India
| | | | - Raghuram Rao
- National Tuberculosis Elimination Programme, India Ministry of Health and Family Welfare, New Delhi, India
| | - Kuldeep S Sachdeva
- South-East Asia Office, International Union Against Tuberculosis and Lung Disease, New Delhi, India
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Huddart S, Ingawale P, Edwin J, Jondhale V, Pai M, Benedetti A, Shah D, Vijayan S. TB case fatality and recurrence in a private sector cohort in Mumbai, India. Int J Tuberc Lung Dis 2021; 25:738-746. [PMID: 34802496 PMCID: PMC8412104 DOI: 10.5588/ijtld.21.0266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: Half of India´s three million TB patients are treated in the largely unregulated private sector, where quality of care is often poor. Private provider interface agencies (PPIAs) seek to improve private sector quality of care, which can be measured in terms of case fatality and recurrence rates.METHODS: We conducted a retrospective cohort survey of 4,000 private sector patients managed by the PATH PPIA between 2014 and 2017. We estimated treatment and post-treatment case-fatality ratios (CFRs) and recurrence rates. We used Cox proportional hazards models to identify predictors of fatality and recurrence. Patient loss to follow-up was adjusted for using selection weighting.RESULTS: The treatment CFR was 7.1% (95% CI 6.0-8.2). At 24 months post-treatment, the CFR was 2.4% (95% CI 1.7-3.0) and the recurrence rate was 1.9% (95% CI 1.3-2.5). Treatment fatality was associated with age (HR 1.02, 95% CI 1.02-1.03), clinical diagnosis (HR 0.61, 95% CI 0.45-0.84), treatment duration (HR 0.09, 95% CI 0.06-0.10) and adherence. Post-treatment fatality was associated with treatment duration (HR 0.87, 95% CI 0.79-0.91) and adherence.CONCLUSIONS: We found a moderate treatment phase CFR among PPIA-managed private sector patient with low rates of post-treatment fatality and recurrence. Routine monitoring of patient outcomes after treatment would strengthen PPIAs and inform future post TB interventions.
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Affiliation(s)
- S Huddart
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, McGill International TB Centre, Montreal, QC, Canada
| | | | | | | | - M Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, McGill International TB Centre, Montreal, QC, Canada, Manipal McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, India
| | - A Benedetti
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC
| | - D Shah
- Mumbai Municipal Corporation, Mumbai, India
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Lungu P, Kerkhoff AD, Kasapo CC, Mzyece J, Nyimbili S, Chimzizi R, Silumesii A, Kagujje M, Subbaraman R, Muyoyeta M, Malama K. Tuberculosis care cascade in Zambia - identifying the gaps in order to improve outcomes: a population-based analysis. BMJ Open 2021; 11:e044867. [PMID: 34376439 PMCID: PMC8356169 DOI: 10.1136/bmjopen-2020-044867] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Tuberculosis (TB) remains a leading cause of morbidity and mortality in Zambia, especially for people living with HIV (PLHIV). We undertook a care cascade analysis to quantify gaps in care and align programme improvement measures with areas of need. DESIGN Retrospective, population-based analysis. SETTING We derived national-level estimates for each step of the TB care cascade in Zambia. Estimates were informed by WHO incidence estimates, nationally aggregated laboratory and notification registers, and individual-level programme data from four provinces. PARTICIPANTS Participants included all individuals with active TB disease in Zambia in 2018. We characterised the overall TB cascade and disaggregated by drug susceptibility results and HIV status. RESULTS In 2018, the total burden of TB in Zambia was estimated to be 72 495 (range, 40 495-111 495) cases. Of these, 43 387 (59.8%) accessed TB testing, 40 176 (55.4%) were diagnosed with TB, 36 431 (50.3%) were started on treatment and 32 700 (45.1%) completed treatment. Among all persons with TB lost at any step along the care cascade (n=39 795), 29 108 (73.1%) were lost prior to accessing diagnostic services, 3211 (8.1%) prior to diagnosis, 3745 (9.4%) prior to initiating treatment and 3731 (9.4%) prior to treatment completion. PLHIV were less likely than HIV-negative individuals to successfully complete the care cascade (42.8% vs 50.2%, p<0.001). Among those with rifampicin-resistant TB, there was substantial attrition at each step of the cascade and only 22.8% were estimated to have successfully completed treatment. CONCLUSIONS Losses throughout the care cascade resulted in a large proportion of individuals with TB not completing treatment. Ongoing health systems strengthening and patient-centred engagement strategies are needed at every step of the care cascade; however, scale-up of active case finding strategies is particularly critical to ensure individuals with TB in the population reach initial stages of care. Additionally, a renewed focus on PLHIV and individuals with drug-resistant TB is urgently needed to improve TB-related outcomes in Zambia.
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Affiliation(s)
- Patrick Lungu
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, California, USA
| | - Clara C Kasapo
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
| | - Judith Mzyece
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
| | - Sulani Nyimbili
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
| | - Rhehab Chimzizi
- National Tuberculosis and Leprosy Control Programme, Lusaka, Zambia
| | - Andrew Silumesii
- Department of Public Health and Research, Ministry of Health, Lusaka, Zambia
| | - Mary Kagujje
- Tuberculosis Department, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ramnath Subbaraman
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Monde Muyoyeta
- Tuberculosis Department, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
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Wulandari LPL, Khan M, Liverani M, Ferdiana A, Mashuri YA, Probandari A, Wibawa T, Batura N, Schierhout G, Kaldor J, Guy R, Law M, Day R, Hanefeld J, Parathon H, Jan S, Yeung S, Wiseman V. Prevalence and determinants of inappropriate antibiotic dispensing at private drug retail outlets in urban and rural areas of Indonesia: a mixed methods study. BMJ Glob Health 2021; 6:e004993. [PMID: 34344668 PMCID: PMC8336216 DOI: 10.1136/bmjgh-2021-004993] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 06/29/2021] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION The aim of this mixed-method study was to determine the extent and determinants of inappropriate dispensing of antibiotics by licensed private drug retail outlets in Indonesia. METHODS Standardised patients (SPs) made a total of 495 visits to 166 drug outlets (community pharmacies and drug stores) between July and August 2019. The SPs presented three clinical cases to drug outlet staff: parent of a child at home with diarrhoea; an adult with presumptive tuberculosis (TB); and an adult with upper respiratory tract infection (URTI). The primary outcome was the dispensing of an antibiotic without prescription, with or without the client requesting it. We used multivariable random effects logistic regression to assess factors associated with the primary outcome and conducted 31 interviews with drug outlet staff to explore these factors in greater depth. RESULTS Antibiotic dispensing without prescription occurred in 69% of SP visits. Dispensing antibiotics without a prescription was more likely in standalone pharmacies and pharmacies attached to clinics compared with drug stores, with an OR of 5.9 (95% CI 3.2 to 10.8) and OR of 2.2 (95% CI 1.2 to 3.9); and more likely for TB and URTI SP-performed cases compared with child diarrhoea cases, with an OR of 5.7 (95% CI 3.1 to 10.8) and OR of 5.2 (95% CI 2.7 to 9.8). Interviews revealed that inappropriate antibiotic dispensing was driven by strong patient demand for antibiotics, unqualified drug sellers dispensing medicines, competition between different types of drug outlets, drug outlet owners pushing their staff to sell medicines, and weak enforcement of regulations. CONCLUSION This study shows that inappropriate dispensing of antibiotics by private drug retail outlets is widespread. Interventions will need to address not only the role of drug sellers, but also the demand for antibiotics among clients and the push from drug outlet owners to compete with other outlets.
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Affiliation(s)
- Luh Putu Lila Wulandari
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Faculty of Medicine, Universitas Udayana, Denpasar, Bali, Indonesia
| | - Mishal Khan
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- Pathology & Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Astri Ferdiana
- Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Faculty of Medicine, Universitas Mataram, Mataram, Nusa Tenggara Barat, Indonesia
| | - Yusuf Ari Mashuri
- Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Jawa Tengah, Indonesia
| | - Ari Probandari
- Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Jawa Tengah, Indonesia
| | - Tri Wibawa
- Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Neha Batura
- Institute for Global Health, University College London, London, UK
| | - Gill Schierhout
- The George Institute for Global Health, UNSW Sydney, Newtown, New South Wales, Australia
| | - John Kaldor
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Rebecca Guy
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Matthew Law
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Richard Day
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Johanna Hanefeld
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- Centre for International Health Protection, Robert Koch Institute, Berlin, Germany
| | - Harry Parathon
- Antibiotic Resistance Control Committee, Indonesian Ministry of Health, Jakarta, Indonesia
| | - Stephen Jan
- The George Institute for Global Health, UNSW Sydney, Newtown, New South Wales, Australia
| | - Shunmay Yeung
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Virginia Wiseman
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Khan MS, Durrance-Bagale A, Mateus A, Sultana Z, Hasan R, Hanefeld J. What are the barriers to implementing national antimicrobial resistance action plans? A novel mixed-methods policy analysis in Pakistan. Health Policy Plan 2021; 35:973-982. [PMID: 32743655 DOI: 10.1093/heapol/czaa065] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2020] [Indexed: 12/25/2022] Open
Abstract
Despite political commitment to address antimicrobial resistance (AMR), countries are facing challenges to implementing policies to reduce inappropriate use of antibiotics. Critical factors to the success of policy implementation in low- and middle-income countries (LMIC), such as capacity for enforcement, contestation by influential stakeholders and financial interests, have been insufficiently considered. Using Pakistan as a case study representing a populous country with extremely high antibiotic usage, we identified 195 actors who affect policies on antibiotic use in humans and animals through a snowballing process and interviewed 48 of these who were nominated as most influential. We used a novel card game-based methodology to investigate policy actors' support for implementation of different regulatory approaches addressing actions of frontline healthcare providers and antibiotic producers across the One Health spectrum. We found that there was only widespread support for implementing hard regulations (prohibiting certain actions) against antibiotic suppliers with little power-such as unqualified/informal healthcare providers and animal feed producers-but not to target more powerful groups such as doctors, farmers and pharmaceutical companies. Policy actors had limited knowledge to develop implementation plans to address inappropriate use of antibiotics in animals, even though this was recognized as a critical driver of AMR. Our results indicate that local political and economic dynamics may be more salient to policy actors influencing implementation of AMR national action plans than solutions presented in global guidelines that rely on implementation of hard regulations. This highlights a disconnect between AMR action plans and the local contexts where implementation takes place. Thus if the global strategies to tackle AMR are to become implementable policies in LMIC, they will need greater appreciation of the power dynamics and systemic constraints that relate to many of the strategies proposed.
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Affiliation(s)
- Mishal S Khan
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Anna Durrance-Bagale
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Ana Mateus
- Department of Pathobiology and Population Sciences, Royal Veterinary College, London WC1H 9SH, UK
| | - Zia Sultana
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi 74800, Pakistan
| | - Rumina Hasan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi 74800, Pakistan.,Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Johanna Hanefeld
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
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Alharbi AA, Alqassim AY, Alharbi AA, Gosadi IM, Aqeeli AA, Muaddi MA, Makeen AM, Alharbi OA. Variations in length of stay of inpatients with COVID-19: A nationwide test of the new model of care under vision 2030 in Saudi Arabia. Saudi J Biol Sci 2021; 28:6631-6638. [PMID: 34305430 PMCID: PMC8289721 DOI: 10.1016/j.sjbs.2021.07.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/06/2021] [Accepted: 07/11/2021] [Indexed: 01/28/2023] Open
Abstract
Objective The coronavirus disease 2019 (COVID-19) has impacted the Kingdom of Saudi Arabia (KSA) as it has other nations. However, length of stay (LOS), as a healthcare quality indicator, has not been examined across the healthcare regions in the KSA. Therefore, this study aimed to examine factors associated with LOS to better understand the Saudi Health System's performance in response to the COVID-19 pandemic in the newly suggested five Saudi regional business units (BUs). Methods A retrospective study was conducted using Ministry of Health (MOH) data on hospital LOS during the period from March to mid-July 2020. Participants were adult inpatients (18 years or older) with confirmed COVID-19 (n = 1743 patients). The 13 regions of the KSA were united into the defined five regional BUs during the reorganization of the health system. Covariates included demographics such as age and sex, comorbidities, and complications of COVID-19. A multiple linear regression with stepwise forward selection was used to model LOS for other explanatory variables associated with LOS, including demographic, comorbidities, and complications. Results The mean LOS was 11.85 days which differed significantly across the BUs, ranging from 9.3 days to 13.3 days (p value < 0.001). BUs differed significantly in LOS for transferred patients but not for patients in the intensive care unit (ICU) or those who died in-hospital. The multiple regression analysis revealed that the LOS for inpatients admitted in the Eastern and Southern BUs was significantly shorter than for those in the Central BU. (p value < 0.001). Admission to the ICU was associated with lengthier stays (p value < 0.0001). Factors significantly associated with shorter stays (compared to the reference), were being Saudi, death during admission, and patients referred to another hospital (p value < 0.05). Conclusion The LOS for patients with COVID-19 differed across the proposed regional healthcare BUs, suggesting regional differences in quality of care under the reorganization of the national health system. Since patient and disease characteristics did not explain these findings, differences in staffing and other resources need to be examined to develop interventions.
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Key Words
- ARDS, Acute Respiratory Distress Syndrome
- CI, Confidence interval
- COVID-19
- COVID-19, Coronavirus disease 2019
- GIT, Gastrointestinal tract
- Hospital admission
- ICU, Intensive care unit
- KSA, Kingdom of Saudi Arabia
- LOS, Length of stay
- Length of stay
- MOC, Model of care
- MOH, Ministry of Health
- OR, Odds Ratio
- Occupational and environmental health
- Saudi Arabia
- Vision 2030
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Affiliation(s)
- Abdullah A. Alharbi
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
- Corresponding author at: 2501 Dar Al-Nassr St., Abu Arish, Jazan 45911, Saudi Arabia.
| | - Ahmad Y. Alqassim
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
| | - Ahmad A. Alharbi
- Internal Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
| | - Ibrahim M. Gosadi
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
| | - Abdulwahab A. Aqeeli
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
| | - Mohammed A. Muaddi
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
| | - Anwar M. Makeen
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
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Affiliation(s)
- Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Dolores Freire Jijon
- Universidad de Guayaquil, Guayaquil, Ecuador
- Division of Pediatric Infectious Diseases, University of Alberta, Edmonton, Canada
| | - Pankaj Pal
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Saurabh Rane
- Wadhani Institute for Artificial Intelligence, Mumbai, India
- Survivors Against TB, India
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Sulis G, Daniels B, Kwan A, Gandra S, Daftary A, Das J, Pai M. Antibiotic overuse in the primary health care setting: a secondary data analysis of standardised patient studies from India, China and Kenya. BMJ Glob Health 2021; 5:bmjgh-2020-003393. [PMID: 32938614 PMCID: PMC7493125 DOI: 10.1136/bmjgh-2020-003393] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction Determining whether antibiotic prescriptions are inappropriate requires knowledge of patients’ underlying conditions. In low-income and middle-income countries (LMICs), where misdiagnoses are frequent, this is challenging. Additionally, such details are often unavailable for prescription audits. Recent studies using standardised patients (SPs) offer a unique opportunity to generate unbiased prevalence estimates of antibiotic overuse, as the research design involves patients with predefined conditions. Methods Secondary analyses of data from nine SP studies were performed to estimate the proportion of SP–provider interactions resulting in inappropriate antibiotic prescribing across primary care settings in three LMICs (China, India and Kenya). In all studies, SPs portrayed conditions for which antibiotics are unnecessary (watery diarrhoea, presumptive tuberculosis (TB), angina and asthma). We conducted descriptive analyses reporting overall prevalence of antibiotic overprescribing by healthcare sector, location, provider qualification and case. The WHO Access–Watch–Reserve framework was used to categorise antibiotics based on their potential for selecting resistance. As richer data were available from India, we examined factors associated with antibiotic overuse in that country through hierarchical Poisson models. Results Across health facilities, antibiotics were given inappropriately in 2392/4798 (49.9%, 95% CI 40.8% to 54.5%) interactions in India, 83/166 (50.0%, 95% CI 42.2% to 57.8%) in Kenya and 259/899 (28.8%, 95% CI 17.8% to 50.8%) in China. Prevalence ratios of antibiotic overuse in India were significantly lower in urban versus rural areas (adjusted prevalence ratio (aPR) 0.70, 95% CI 0.52 to 0.96) and higher for qualified versus non-qualified providers (aPR 1.55, 95% CI 1.42 to 1.70), and for presumptive TB cases versus other conditions (aPR 1.19, 95% CI 1.07 to 1.33). Access antibiotics were predominantly used in Kenya (85%), but Watch antibiotics (mainly quinolones and cephalosporins) were highly prescribed in India (47.6%) and China (32.9%). Conclusion Good-quality SP data indicate alarmingly high levels of antibiotic overprescription for key conditions across primary care settings in India, China and Kenya, with broad-spectrum agents being excessively used in India and China.
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Affiliation(s)
- Giorgia Sulis
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada.,McGill International TB Centre, McGill University, Montreal, Québec, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA
| | - Ada Kwan
- School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Medicine, Washington University in Saint Louis, Saint Louis, Missouri, USA
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, York University, Toronto, Ontario, Canada.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA.,Centre for Policy Research, New Delhi, Delhi, India
| | - Madhukar Pai
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada .,McGill International TB Centre, McGill University, Montreal, Québec, Canada.,Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Engaging Informal Private Health Care Providers for TB Case Detection: Experiences from RIPEND Project in India. Tuberc Res Treat 2021; 2021:9579167. [PMID: 34239728 PMCID: PMC8241510 DOI: 10.1155/2021/9579167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 06/04/2021] [Accepted: 06/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background Informal (unqualified) health care providers are an important source of medical care for persons with presumptive TB (PPTB) in India. A project (titled RIPEND) was implemented to engage informal providers for the identification of PPTBs and TB patients in 4 districts of Telangana State, India, during October 2018-December 2019 project period. Engagement involved sensitizing the informal providers about TB, providing them financial incentives to identify PPTBs, and linking these PPTBs to diagnostic and treatment services provided by the Government of India's National TB Elimination Programme. Objectives To describe (a) the characteristics of the informal providers, along with their self-reported practices on TB diagnosis, treatment, and challenges encountered by the RIPEND project staff in engaging them in the project and (b) the outputs and outcomes of this engagement. Methods We used a combination of one-on-one interviews with informal providers, group interviews with RIPEND project staff, and secondary analysis of data available within the project's recording and reporting systems. Results A total of 555 informal providers were actively engaged under the project. The majority (87%) had a nonmedicine-related graduate degree and had been providing medical care for more than 10 years. Most (95%) were aware that a cough for 2 weeks or more is a symptom of pulmonary TB and that such patients should be referred for sputum-smear microscopy at a government health facility. Challenges in engaging the informal providers included motivating them to participate in the study, suboptimal mobile usage for referral services, and delays in providing financial incentives to them for referring PPTBs. During the project period (October 2018-December 2019), 8342 PPTBs were identified of which 1003 TB patients were detected and linked to TB treatment services. Conclusion This project showed that engaging informal providers is feasible and that a large number of PPTB and TB patients can be identified through this effort. The Government of India should consider engaging informal providers for the early diagnosis of TB to reduce the missing TB cases in the country.
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Aujla N, Ilori T, Irabor A, Obimakinde A, Owoaje E, Fayehun O, Ajisola MM, Bolaji SO, Watson SI, Hofer TP, Omigbodun A, Lilford RJ. Development of a video-observation method for examining doctors' clinical and interpersonal skills in a hospital outpatient clinic in Ibadan, Oyo State, Nigeria. BMC Health Serv Res 2021; 21:488. [PMID: 34022859 PMCID: PMC8141168 DOI: 10.1186/s12913-021-06491-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving the quality of primary healthcare provision is a key goal in low-and middle-income countries (LMICs). However, to develop effective quality improvement interventions, we first need to be able to accurately measure the quality of care. The methods most commonly used to measure the technical quality of care all have some key limitations in LMICs settings. Video-observation is appealing but has not yet been used in this context. We examine preliminary feasibility and acceptability of video-observation for assessing physician quality in a hospital outpatients' department in Nigeria. We also develop measurement procedures and examine measurement characteristics. METHODS Cross-sectional study at a large tertiary care hospital in Ibadan, Nigeria. Consecutive physician-patient consultations with adults and children under five seeking outpatient care were video-recorded. We also conducted brief interviews with participating physicians to gain feedback on our approach. Video-recordings were double-coded by two medically trained researchers, independent of the study team and each other, using an explicit checklist of key processes of care that we developed, from which we derived a process quality score. We also elicited a global quality rating from reviewers. RESULTS We analysed 142 physician-patient consultations. The median process score given by both coders was 100 %. The modal overall rating category was 'above standard' (or 4 on a scale of 1-5). Coders agreed on which rating to assign only 44 % of the time (weighted Cohen's kappa = 0.26). We found in three-level hierarchical modelling that the majority of variance in process scores was explained by coder disagreement. A very high correlation of 0.90 was found between the global quality rating and process quality score across all encounters. Participating physicians liked our approach, despite initial reservations about being observed. CONCLUSIONS Video-observation is feasible and acceptable in this setting, and the quality of consultations was high. However, we found that rater agreement is low but comparable to other modalities that involve expert clinician judgements about quality of care including in-person direct observation and case note review. We suggest ways to improve scoring consistency including careful rater selection and improved design of the measurement procedure for the process score.
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Affiliation(s)
- Navneet Aujla
- Warwick Medical School, University of Warwick, C/O Room B147a, CV4 7AL, Coventry, United Kingdom.
| | - Temitope Ilori
- University College Hospital, Ibadan, Nigeria.,University of Ibadan, Ibadan, Nigeria
| | | | - Abimbola Obimakinde
- University College Hospital, Ibadan, Nigeria.,University of Ibadan, Ibadan, Nigeria
| | | | | | | | | | - Samuel I Watson
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Timothy P Hofer
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Richard J Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
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Di Giorgio L, Evans DK, Lindelow M, Nguyen SN, Svensson J, Wane W, Welander Tärneberg A. Analysis of clinical knowledge, absenteeism and availability of resources for maternal and child health: a cross-sectional quality of care study in 10 African countries. BMJ Glob Health 2021; 5:bmjgh-2020-003377. [PMID: 33355259 PMCID: PMC7751199 DOI: 10.1136/bmjgh-2020-003377] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE Assess the quality of healthcare across African countries based on health providers' clinical knowledge, their clinic attendance and drug availability, with a focus on seven conditions accounting for a large share of child and maternal mortality in sub-Saharan Africa: malaria, tuberculosis, diarrhoea, pneumonia, diabetes, neonatal asphyxia and postpartum haemorrhage. METHODS With nationally representative, cross-sectional data from ten countries in sub-Saharan Africa, collected using clinical vignettes (to assess provider knowledge), unannounced visits (to assess provider absenteeism) and visual inspections of facilities (to assess availability of drugs and equipment), we assess whether health providers are available and have sufficient knowledge and means to diagnose and treat patients suffering from common conditions amenable to primary healthcare. We draw on data from 8061 primary and secondary care facilities in Kenya, Madagascar, Mozambique, Nigeria, Niger, Senegal, Sierra Leone, Tanzania, Togo and Uganda, and 22 746 health workers including doctors, clinical officers, nurses and community health workers. Facilities were selected using a multistage cluster-sampling design to ensure data were representative of rural and urban areas, private and public facilities, and of different facility types. These data were gathered under the Service Delivery Indicators programme. RESULTS Across all conditions and countries, healthcare providers were able to correctly diagnose 64% (95% CI 62% to 65%) of the clinical vignette cases, and in 45% (95% CI 43% to 46%) of the cases, the treatment plan was aligned with the correct diagnosis. For diarrhoea and pneumonia, two common causes of under-5 deaths, 27% (95% CI 25% to 29%) of the providers correctly diagnosed and prescribed the appropriate treatment for both conditions. On average, 70% of health workers were present in the facilities to provide care during facility hours when those workers are scheduled to be on duty. Taken together, we estimate that the likelihood that a facility has at least one staff present with competency and key inputs required to provide child, neonatal and maternity care that meets minimum quality standards is 14%. On average, poor clinical knowledge is a greater constraint in care readiness than drug availability or health workers' absenteeism in the 10 countries. However, we document substantial heterogeneity across countries in the extent to which drug availability and absenteeism matter quantitatively. CONCLUSION Our findings highlight the need to boost the knowledge of healthcare workers to achieve greater care readiness. Training programmes have shown mixed results, so systems may need to adopt a combination of competency-based preservice and in-service training for healthcare providers (with evaluation to ensure the effectiveness of the training), and hiring practices that ensure the most prepared workers enter the systems. We conclude that in settings where clinical knowledge is poor, improving drug availability or reducing health workers' absenteeism would only modestly increase the average care readiness that meets minimum quality standards.
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Affiliation(s)
| | | | | | | | - Jakob Svensson
- Institute for International Economic Studies, Stockholm University, Stockholm, Sweden
| | - Waly Wane
- World Bank Côte d'Ivoire Office, Abidjan, Côte d'Ivoire
| | - Anna Welander Tärneberg
- Centre for Economic Demography and Department of Economic History, Lund University School of Economics and Management, Lund, Sweden
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Alharbi AA, Alqassim AY, Gosadi IM, Aqeeli AA, Muaddi MA, Makeen AM, Alhazmi AH, Alharbi AA. Regional differences in COVID-19 ICU admission rates in the Kingdom of Saudi Arabia: A simulation of the new model of care under vision 2030. J Infect Public Health 2021; 14:717-723. [PMID: 34020211 PMCID: PMC8113109 DOI: 10.1016/j.jiph.2021.04.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/08/2021] [Accepted: 04/27/2021] [Indexed: 01/28/2023] Open
Abstract
Objective Saudi Arabia has succeeded in having one of the lowest rates of COVID-19 worldwide due to the government’s initiatives in taking swift action to control both the spread and severity of the virus. However, Covid-19 can serve as a test case of the expected response of the new healthcare system under Vision 2030. This study used data from the thirteen present administrative regions of KSA to simulate the variations in ICU admission as a quality indicator in the five business units proposed by a new Model of Care. Methods We determined the rates of ICU admission for patients with confirmed SARS-CoV-2 (COVID-19) from March to mid-July 2020. The final sample included 1743 inpatients with moderate to severe COVID-19. Patient characteristics, including demographics, pre-existing chronic conditions, and COVID-19 complications, were collected. Business units (BUs) were compared with respect to the relative odds of ICU admission by using multiple logistic regression. Results After keeping patient and clinical characteristics constant, clear BU differences were observed in the relative odds of ICU admission of COVID-19 patients. Inpatient admission to ICU in our total sample was almost 50%. Compared to the Central BU, the Northern and Western BUs showed significantly higher odds of ICU admission while the Eastern & Southern BUs had significantly lower odds. Conclusion ICU use for COVID-19 patients differed significantly in KSA healthcare BUs, consistent with variations in care for other non-COVID-19-related conditions. These differences cannot be explained by patient or clinical characteristics, suggesting quality-of-care differences. We believe that privatization and the shift to fewer administrative BUs will help lessen or eliminate altogether the present variations in healthcare service provision.
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Affiliation(s)
- Abdullah A Alharbi
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia.
| | - Ahmad Y Alqassim
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
| | - Ibrahim M Gosadi
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
| | - Abdulwahab A Aqeeli
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
| | - Mohammed A Muaddi
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
| | - Anwar M Makeen
- Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
| | - Abdulaziz H Alhazmi
- Microbiology and Medical Parasitology Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
| | - Ahmad A Alharbi
- Internal Medicine Department, Faculty of Medicine, Jazan University, Jazan City, Jazan, Saudi Arabia
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Boffa J, Moyo S, Chikovore J, Salomon A, Daniels B, Kwan AT, Pai M, Daftary A. Quality of care for tuberculosis and HIV in the private health sector: a cross-sectional, standardised patient study in South Africa. BMJ Glob Health 2021; 6:e005250. [PMID: 33990360 PMCID: PMC8127976 DOI: 10.1136/bmjgh-2021-005250] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/07/2021] [Accepted: 04/19/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND South Africa has high burdens of tuberculosis (TB) and TB-HIV, yet the quality of patient care in the private sector is unknown. We describe quality of TB and TB-HIV care among private general practitioners (GPs) in two South African cities using standardised patients (SPs). METHODS Sixteen SPs presented one of three cases during unannounced visits to private GPs in selected high-TB burden communities in Durban and Cape Town: case 1, typical TB symptoms, HIV-positive; case 2, TB-specified laboratory report, HIV-negative and case 3, history of incomplete TB treatment, HIV-positive. Clinical practices were recorded in standardised exit interviews. Ideal management was defined as relevant testing or public sector referral for any reason. The difference between knowledge and practice (know-do gap) was assessed through case 1 vignettes among 25% of GPs. Factors associated with ideal management were assessed using bivariate logistic regression. RESULTS 511 SP visits were completed with 212 GPs. Respectively, TB and HIV were ideally managed in 43% (95% CI 36% to 50%) and 41% (95% CI 34% to 48%) of case 1, 85% (95% CI 78% to 90%) and 61% (95% CI 73% to 86%) of case 2 and 69% (95% CI 61% to 76%) and 80% (95% CI 52% to 68%) of case 3 presentations. HIV status was queried in 35% (95% CI 31% to 39%) of visits, least with case 1 (24%, 95% CI 18% to 30%). The difference between knowledge and practice was 80% versus 43% for TB and 55% versus 37% for HIV, resulting in know-do gaps of 37% (95% CI 19% to 55%) and 18% (95% CI -1% to 38%), respectively. Ideal TB management was associated with longer visit time (OR=1.1, 95% CI 1.1 to 1.2), female GPs (3.2, 95% CI 2.0 to 5.1), basic symptom inquiry (2.0, 95% CI 1.7 to 2.3), HIV-status inquiry (OR=11.2, 95% CI 6.4 to 19.6), fewer medications dispensed (OR=0.6, 95% CI 0.5 to 0.7) and Cape Town (OR=2.2, 95% CI 1.5 to 3.1). Similar associations were observed for HIV. CONCLUSIONS Private providers ideally managed TB more often when a diagnosis or history of TB was implied or provided. Management of HIV in the context of TB was less than optimal.
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Affiliation(s)
- Jody Boffa
- Dahdaleh Institute of Global Health Research, York University, Toronto, Ontario, Canada
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Sizulu Moyo
- Human and Social Capabilities Division, Human Sciences Research Council, Cape Town, South Africa
- School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Jeremiah Chikovore
- Human and Social Capabilities Division, Human Sciences Research Council, Durban, South Africa
| | - Angela Salomon
- McGill International TB Centre, McGill University, Montreal, Québec, Canada
| | - Benjamin Daniels
- International Public Health, Georgetown University, Washington, DC, USA
| | - Ada T Kwan
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Québec, Canada
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, York University, Toronto, Ontario, Canada
- School of Global Health, York University, Toronto, Ontario, Canada
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
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Aujla N, Chen YF, Samarakoon Y, Wilson A, Grolmusová N, Ayorinde A, Hofer TP, Griffiths F, Brown C, Gill P, Mallen C, Sartori J, Lilford RJ. Comparing the use of direct observation, standardized patients and exit interviews in low- and middle-income countries: a systematic review of methods of assessing quality of primary care. Health Policy Plan 2021; 36:341-356. [PMID: 33313845 PMCID: PMC8058951 DOI: 10.1093/heapol/czaa152] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2020] [Indexed: 12/31/2022] Open
Abstract
Clinical records in primary healthcare settings in low- and middle-income countries (LMIC) are often lacking or of too poor quality to accurately assess what happens during the patient consultation. We examined the most common methods for assessing healthcare workers' clinical behaviour: direct observation, standardized patients and patient/healthcare worker exit interview. The comparative feasibility, acceptability, reliability, validity and practicalities of using these methods in this setting are unclear. We systematically review and synthesize the evidence to compare and contrast the advantages and disadvantages of each method. We include studies in LMICs where methods have been directly compared and systematic and narrative reviews of each method. We searched several electronic databases and focused on real-life (not educational) primary healthcare encounters. The most recent update to the search for direct comparison studies was November 2019. We updated the search for systematic and narrative reviews on the standardized patient method in March 2020 and expanded it to all methods. Search strategies combined indexed terms and keywords. We searched reference lists of eligible articles and sourced additional references from relevant review articles. Titles and abstracts were independently screened by two reviewers and discrepancies resolved through discussion. Data were iteratively coded according to pre-defined categories and synthesized. We included 12 direct comparison studies and eight systematic and narrative reviews. We found that no method was clearly superior to the others-each has pros and cons and may assess different aspects of quality of care provision by healthcare workers. All methods require careful preparation, though the exact domain of quality assessed and ethics and selection and training of personnel are nuanced and the methods were subject to different biases. The differential strengths suggest that individual methods should be used strategically based on the research question or in combination for comprehensive global assessments of quality.
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Affiliation(s)
- Navneet Aujla
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Yen-Fu Chen
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Yasara Samarakoon
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Anna Wilson
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Natalia Grolmusová
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Abimbola Ayorinde
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Timothy P Hofer
- Department of Medicine, UM Institute for Health Policy and Innovation, Building 16 3rd Floor, North Campus Research Centre, University of Michigan Medical School, Ann Arbor, MI 48109-2800 USA
| | - Frances Griffiths
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Celia Brown
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Paramjit Gill
- W-CAHRD, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Christian Mallen
- Keele School of Medicine, David Wetherall Building, Keele University, Keele, ST5 5BG, UK
| | - Jo Sartori
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Richard J Lilford
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Huddart S, Singh M, Jha N, Benedetti A, Pai M. Case fatality and recurrent tuberculosis among patients managed in the private sector: A cohort study in Patna, India. PLoS One 2021; 16:e0249225. [PMID: 33770134 PMCID: PMC7996982 DOI: 10.1371/journal.pone.0249225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/14/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A key component of the WHO End TB Strategy is quality of care, for which case fatality is a critical marker. Half of India's nearly 3 million TB patients are treated in the highly unregulated private sector, yet little is known about the outcomes of these patients. Using a retrospective cohort design, we estimated the case fatality ratio (CFR) and rate of recurrent TB among patients managed in the private healthcare sector in Patna, India. METHODS World Health Partners' Private Provider Interface Agencies (PPIA) pilot project in Patna has treated 89,906 private sector TB patients since 2013. A random sample of 4,000 patients treated from 2014 to 2016 were surveyed in 2018 for case fatality and recurrent TB. CFR is defined as the proportion of patients who die during the period of interest. Treatment CFRs, post-treatment CFRs and rates of recurrent TB were estimated. Predictors for fatality and recurrence were identified using Cox proportional hazards modelling. Survey non-response was adjusted for using inverse probability selection weighting. RESULTS The survey response rate was 56.0%. The weighted average follow-up times were 8.7 months in the treatment phase and 26.4 months in the post-treatment phase. Unobserved patients were more likely to have less than one month of treatment adherence (32.0% vs. 13.5%) and were more likely to live in rural Patna (21.9% vs. 15.0%). The adjusted treatment phase CFR was 7.27% (5.97%, 8.49%) and at 24 months post-treatment was 3.32% (2.36%, 4.42%). The adjusted 24 month post-treatment phase recurrent TB rate was 3.56% (2.54%, 4.79%). CONCLUSIONS Our cohort study provides critical estimates of TB patient outcomes in the Indian private sector, and accounts for selection bias. Patients in the private sector in Patna experienced a moderate treatment CFR but rates of recurrent TB and post-treatment fatality were low.
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Affiliation(s)
- Sophie Huddart
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
- Faculty of Medicine, University of California-San Francisco, San Francisco, CA, United States of America
| | | | - Nita Jha
- World Health Partners, Patna, India
| | - Andrea Benedetti
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
- Manipal McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, India
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Gautam AS, Pathak N, Ahamad T, Semwal P, Bourai AA, Rana AS, Nautiyal OP. Pandemic in India: Special reference to Covid-19 and its technological aspect. JOURNAL OF STATISTICS & MANAGEMENT SYSTEMS 2021. [DOI: 10.1080/09720510.2021.1879469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Alok Sagar Gautam
- Department of Physics, Hemvati Nandan Bahuguna Garhwal University (A Central University), Srinagar, Garhwal 246174, Uttarakhand, India
| | - Nishit Pathak
- Department of Pharmaceutical Science and Chinese Central Medicines, South West University Chongqing, Chongqing 400715, China
| | - Taufiq Ahamad
- Department of Physics, Shri Guru Ram Rai Post Graduate College, Dehradun 248001, Uttarakhand, India
| | - Poonam Semwal
- Department of Physics, Government Post Graduation College New Tehri, Tehri Garhwal 249001, Uttarakhand, India
| | - A. A. Bourai
- Department of Physics, H. N. B. Garhwal University, Badshahithaul Campus, Tehri Garhwal 249199, Uttarakhand, India
| | - A. S. Rana
- Department of Physics, Shri Guru Ram Rai Post Graduate College, Dehradun 248001, Uttarakhand, India
| | - O. P. Nautiyal
- Uttarakhand Science Education and Research Centre, Dehradun 248001, Uttarakhand, India
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Sudharsanan N, Ali MK, McConnell M. Hypertension knowledge and treatment initiation, adherence, and discontinuation among adults in Chennai, India: a cross-sectional study. BMJ Open 2021; 11:e040252. [PMID: 33472779 PMCID: PMC7818807 DOI: 10.1136/bmjopen-2020-040252] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION A substantial share of urban Indians with diagnosed hypertension do not take regular treatment, potentially due to poor knowledge of hypertension consequences and treatment options. We describe hypertension knowledge and beliefs, treatment patterns, and reported reasons for treatment non-use among adults with diagnosed hypertension in Chennai, India. METHODS We collected data on 833 adults ages 30+ with physician diagnosed hypertension using a door-to-door household survey within randomly selected wards of Chennai. We described the proportion of individuals who were not taking daily medications and their reported reasons for not doing so. Next, we described individuals' knowledge of hypertension consequences and how to control blood pressure (BP) and assessed the association between knowledge and daily treatment use. RESULTS Over one quarter (28% (95% CI 25% to 31%)) of diagnosed individuals reported not taking daily treatment. The largest proportion (18% (95% CI 16% to 21%)) were individuals who had discontinued prior treatment use. The primary reason individuals reported for non-daily use was that their BP had returned to normal. Just 23% (95% CI 20% to 26%) of individuals listed BP medications as the most effective way to reduce BP; however, these individuals were 11% points (95% CI 4% to 19%) more likely to take daily medications. Conversely, 43% (95% CI 40% to 47%) of individuals believed that BP medications should be stopped from time to time and these individuals were 15% points (95% CI -0.21 to -0.09) less likely to take daily treatment. While awareness of the consequences of hypertension was poor, we found no evidence that it was associated with taking daily medications. CONCLUSIONS There were large gaps in consistency of BP medication use which were strongly associated with knowledge about BP medications. Further research is needed to identify whether addressing beliefs can improve daily treatment use among individuals with diagnosed hypertension.
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Affiliation(s)
- Nikkil Sudharsanan
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- LEAD at Krea University, Chennai, India
| | - Mohammed K Ali
- Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Deo S, Jindal P, Sabharwal M, Parulkar A, Singh R, Kadam R, Dabas H, Dewan P. Field sales force model to increase adoption of a novel tuberculosis diagnostic test among private providers: evidence from India. BMJ Glob Health 2020; 5:bmjgh-2020-003600. [PMID: 33376100 PMCID: PMC7778745 DOI: 10.1136/bmjgh-2020-003600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/30/2020] [Accepted: 12/03/2020] [Indexed: 11/16/2022] Open
Abstract
Background Impact of novel high-quality tuberculosis (TB) tests such as Xpert MTB/RIF has been limited due to low uptake among private providers in high-burden countries including India. Our objective was to assess the impact of a demand generation intervention comprising field sales force on the uptake of high-quality TB tests by providers and its financial sustainability for private labs in the long run. Methods We implemented a demand generation intervention across five Indian cities between October 2014 and June 2016 and compared the change in the quantity of Xpert cartridges ordered by labs in these cities from before (February 2013–September 2014) to after intervention (October 2014–December 2015) to corresponding change in labs in comparable non-intervention cities. We embedded this difference-in-differences estimate within a financial model to calculate the internal rate of return (IRR) if the labs were to invest in an Xpert machine with or without the demand generation intervention. Results The intervention resulted in an estimated 60 additional Xpert cartridges ordered per lab-month in the intervention group, which yielded an estimated increase of 11 500 tests over the post-intervention period, at an additional cost of US$13.3–US$17.63 per test. Further, we found that investing in this intervention would increase the IRR from 4.8% to 5.5% for hospital labs but yield a negative IRR for standalone labs. Conclusions Field sales force model can generate additional demand for Xpert at private labs, but additional strategies may be needed to ensure its financial sustainability.
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Affiliation(s)
- Sarang Deo
- Max Institute of Healthcare Management, Indian School of Business, Mohali, Punjab, India .,Operations Management, Indian School of Business, Hyderabad, Telangana, India
| | - Pankaj Jindal
- Operations Management, Indian School of Business, Hyderabad, Telangana, India
| | | | | | - Ritu Singh
- Clinton Health Access Initiative, New Delhi, India
| | | | | | - Puneet Dewan
- Bill and Melinda Gates Foundation, New Delhi, India
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Suresh R, Ruban S, Kumar S. TB care for women and Covid-A double health crisis in the offing? Health Care Women Int 2020; 41:1226-1239. [DOI: 10.1080/07399332.2020.1837135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Rajani Suresh
- Post-Graduate Department of Business Administration, AIMIT, St Aloysius College (Autonomous), Mangalore, India
| | - S. Ruban
- PG Department of Information Technology, AIMIT, St Aloysius College (Autonomous), Mangalore, India
| | - Saurabh Kumar
- Department of Community Medicine, Father Muller Medical College, Mangalore, India
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Shrinivasan R, Rane S, Pai M. India's syndemic of tuberculosis and COVID-19. BMJ Glob Health 2020; 5:e003979. [PMID: 33199280 PMCID: PMC7670552 DOI: 10.1136/bmjgh-2020-003979] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
| | | | - Madhukar Pai
- Department of Epidemiology and Biostatistics & McGill International TB Centre, McGill University, Montreal, Québec, Canada
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Daniels B. Primary care providers are, fundamentally, risk managers - And this is a challenge for health policy. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2020; 3:100037. [PMID: 34327385 PMCID: PMC8315607 DOI: 10.1016/j.lanwpc.2020.100037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 09/21/2020] [Indexed: 11/23/2022]
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