The effects on tuberculosis treatment adherence from utilising community health workers: a comparison of selected rural and urban settings in Kenya

Examining the referral of patients with elevated blood pressure to health resources in an under-resourced community in South Africa

BACKGROUND

Low-and-middle income countries face a disproportionate burden of non-communicable diseases (NCDs) that threaten to overwhelm under-resourced health systems. Community health workers (CHWs) can promote NCD prevention, reach patients, and connect them to local community health resources; however, little has been done to examine how referrals to these resources are utilized by community members. The purpose of this study is to examine the use of referrals to community-based health resources and investigate the factors influencing patient utilization of referrals connecting them to appropriate health resources for elevated blood pressure (BP).

METHODS

CHWs conducted home visits, which included BP screening and brief counseling, with community members in Soweto, South Africa. Participants with elevated (systolic BP: 121-139/ diastolic BP: 81-89 mmHg) or high (≥ 140/90 mmHg) BP were referred to either a local, community-based physical activity (PA) program managed by a non-governmental organization or local health clinics. The number of participants that received and utilized their referrals was tracked. Follow-up interviews were conducted with individuals given a referral who: (1) went to the PA program, (2) did not go to the PA program, (3) went to a clinic, and (4) did not go to a clinic. Interviews were transcribed and analyzed to identify common themes and differences between groups regarding their decisions to utilize the referrals.

RESULTS

CHWs visited 1056 homes, with 1001 community members consenting to the screening; 29.2% (n = 292) of adults were classified as having optimal BP (≤120/80 mmHg), 35.8% (n = 359) had elevated BP, and 35.0% (n = 350) had high BP. One hundred and seventy-three participants accepted a referral to the PA program with 46 (26.6%) enrolling. Five themes emerged from the interviews: (1) prior knowledge and thoughts on BP, (2) psychosocial factors associated with BP control, (3) perception about receiving the referral, (4) contextual factors influencing referral utilization, and (5) perceived benefits of utilizing the referral.

CONCLUSION

CHWs can successfully increase community members' access to health resources by providing appropriate referrals. However, greater attention needs to address community members' barriers and hesitancy to utilize health resources.

Improving hypertension awareness and management in Vietnam through a community-based model

Hypertension prevalence in Vietnam is high, but few people are aware of their disease status. Detection, diagnosis, and treatment are limited, so new approaches are needed to improve awareness and manage the condition, especially at the primary health care level. The Communities for Healthy Hearts programme operated in four districts of Ho Chi Minh City, with the aim of increasing awareness and ensuring linkage to care. Interventions focused on extending services beyond health facilities to convenient community locations; training cadres of community volunteers to screen, refer, and follow up with clients; training health workers in facilities to diagnose, educate, and manage patients referred from the community; and supporting the process with digital case tracking. Community-based blood pressure screenings took place in client homes, commune health stations, and non-traditional sites such as coffee shops, dentists' offices, marketplaces, neighbourhood watch/security posts, and tailor shops. In total, 121,273 adults aged 40 and older were screened. Of these, 25.1% had elevated blood pressure or a previous hypertension diagnosis and were referred to health facilities. Of those referred, 56.2% were confirmed to have hypertension, and of those confirmed, 75.2% were treated. Of those treated, 51.0% achieved blood pressure control, a favourable outcome over past programmes.

Determinants of tuberculosis treatment interruption among patients in Vihiga County, Kenya

BACKGROUND

Despite robust Tuberculosis (TB) program with effective chemotherapy and high coverage, treatment interruption remains a serious problem. Interrupting TB treatment means that patients remain infectious for longer time and are at risk of developing drug resistance and death. This study was conducted to identify and describe predictors of TB treatment interruption.

METHODS

A cohort of 291 notified TB patients from 20 selected health facilities in Vihiga County were enrolled in to the study and followed up until the end of treatment. Patient characteristics that potentially predict treatment interruption were recorded during treatment initiation using structured questionnaires. Patients who interrupted treatment were traced and reasons for stoppage of treatment recorded. Kaplan Meier method was used to estimate probabilities of treatment interruption by patient characteristics and determine time intervals. The Log rank test for the equality of survival distributions analyzed significance of survival differences among categorical variables. For multivariable analysis, Cox proportional hazard model, was fitted to identify predictors of TB treatment interruption through calculation of hazard ratios with 95% Confidence Intervals (CIs). For variable analysis, statistical significance was set at P ≤ 0.05. Reasons for treatment interruption were categorized according to most recurrent behavioral or experiential characteristics.

RESULTS

Participants' median age was 40 years (IQR = 32-53) and 72% were male. Of the 291 patients, 11% (n = 32) interrupted treatment. Incidences of treatment interruption significantly occurred during intensive phase of treatment. Independent predictors of treatment interruption included alcohol consumption (HR = 9.2, 95% CI; 2.6-32.5, p < 0.001), being female (HR = 5.01, 95% CI; 1.68-15.0, p = 0.004), having primary or lower education level (HR = 3.09, 95% CI; 1.13-8.49, p < 0.029) and having a treatment supporter (HR = 0.33, 95% CI; 0.14-0.76, p = 0.009). Reasons for interrupting treatment were categorized as: alcoholism, feeling better after treatment initiation, associated TB stigma, long distance to health facility, lack of food, perception of not having TB and pill burden.

CONCLUSION

TB treatment interruption was high and largely associated with patients' socio-demographic and behavioral characteristics. These multidimensional factors suggest the need for interventions that not only target individual patients but also environment in which they live and receive healthcare services.

Community health workers to improve adherence to anti-seizure medication in rural South Africa: Is it cost-effective?

OBJECTIVE

Epilepsy is a common, chronic neurological disorder that disproportionately affects individuals living in low- and middle-income countries (LMICs), where the treatment gap remains high and adherence to medication remains low. Community health workers (CHWs) have been shown to be effective at improving adherence to chronic medications, yet no study assessing the costs of CHWs in epilepsy management has been reported.

METHODS

Using a Markov model with age- and sex-varying transition probabilities, we determined whether deploying CHWs to improve epilepsy treatment adherence in rural South Africa would be cost-effective. Data were derived using published studies from rural South Africa. Official statistics and international disability weights provided cost and health state values, respectively, and health gains were measured using quality adjusted life years (QALYs).

RESULTS

The intervention was estimated at International Dollars ($) 123 250 per annum per sub-district community and cost $1494 and $1857 per QALY gained for males and females, respectively. Assuming a costlier intervention and lower effectiveness, cost per QALY was still less than South Africa's Gross Domestic Product per capita of $13 215, the cost-effectiveness threshold applied.

SIGNIFICANCE

CHWs would be cost-effective and the intervention dominated even when costs and effects of the intervention were unfavorably varied. Health system re-engineering currently underway in South Africa identifies CHWs as vital links in primary health care, thereby ensuring sustainability of the intervention. Further research on understanding local health state utility values and cost-effectiveness thresholds could further inform the current model, and undertaking the proposed intervention would provide better estimates of its efficacy on reducing the epilepsy treatment gap in rural South Africa.

Expanding the use of community health workers in urban settings: a potential strategy for progress towards universal health coverage

Community health worker (CHW) programmes have been used for decades to improve access to health services in rural settings in low- and middle-income countries. With more than half of the world's population currently living in urban areas and this population expected to grow, equitable access to health services in urban areas is critically important. To understand the extent to which CHW programmes have been successfully deployed in low-income urban settings, we conducted a review of the literature between 2000 and 2018 to identify studies evaluating and describing CHW programmes implemented fully or partially in urban or peri-urban settings. We identified 32 peer-reviewed articles that met our inclusion criteria. Benefits have been documented in several urban settings in low- and middle-income countries including those to address TB/HIV, child health, maternal health and non-communicable diseases through a variety of study designs.

Community health volunteers' contribution to tuberculosis patients notified to National Tuberculosis program through contact investigation in Kenya

BACKGROUND

Contact investigation is important in finding contacts of people who have Tuberculosis (TB) disease so that they can be given treatment and stop further transmission. The main objective of this study was to assess the contribution of community health volunteers (CHVs) to the number of TB patients notified to the National program in Kenya through household contact screening and referral of persons with TB signs and symptoms to the facilities for further investigation.

METHODS

This was a retrospective desk review of project reports submitted to Amref Health Africa in Kenya by the sub-recipients implementing activities in the 33 counties with Case Notification Rate (CNR) of less 175/100,000 and Treatment Success Rate (TRS) of less than 88% as per the National strategic plan 2015-2018. Data for this study covered a period between January and December 2016. Data on the notified TB patients was obtained from the National Tuberculosis Information Basic Unit (TIBU). The study population included all the TB index cases whose households were visited by CHVs for contact screening. Data was recorded into excel spreadsheets where the descriptive analysis was done, proportions calculated and summarized in a table.

RESULTS

Community health volunteers visited a total of 26,307 TB patients (index cases) in their households for contact screening. A total of 44,617 household members were screened for TB with 43,012 (96.40%) from households of bacteriologically confirmed TB patients and 1606 (3.60%) from households of children under 5 years. The proportion of the persons referred to the number screened was 19.6% for those over 5 years and 21.9% from under 5 years with almost the same percentages for males and females at 19.2% and 19.7% respectively. The percentage of (TB) cases identified through tracing of contacts in these counties improved to 10% (5456) of the 54,913 cases notified to the National TB Program.

CONCLUSIONS

This study showed that in the 33 counties of Global Fund TB project implementation, the percentage of TB cases identified through tracing of contacts improved from 6 to 10% while the percentage of notified TB cases; all forms contributed through community referrals improved from 4 to 8%. Community health volunteers can play an effective role in household contact screening and referrals for the identification of TB.

Implementation status of household contact tuberculosis screening by health extension workers: assessment findings from programme implementation in Tigray region, northern Ethiopia

Background

In the Tigray region of Ethiopia, Health Extension Workers (HEWs) conduct Tuberculosis (TB) screening for all household (HH) contacts. However, there is limited evidence on implementation status of HH contact TB screening by HEWs. The aim of this program assessment was to describe the implementation status and associated factors of HH contact TB screening by HEWs.

Methods

This programme assessment was conducted in three randomly selected districts from March to April 2018. Data was collected by using pre-tested structured questionnaire. Descriptive statistics was carried out using frequency tables. Logistic regression analysis was done to identify factors associated with HH contacts screening by HEWs.

Results

In this programme assessment a total of HHs of 411 index TB cases were included. One-fifth (21.7%) of index TB cases had at least one HH contact screened for TB by HEWs. Having TB treatment supporter (TTS) during intensive phase of index TB case (AOR = 2.55, 95% CI: 1.06–6.01), health education on TB to HH contacts by HEWs (AOR = 4.28, 95% CI: 2.04–9.00), HH visit by HEWs within 6 months prior to the programme assessment (AOR = 5.84, 95% CI: 2.81–12.17) and discussions about TB activities by HEWs with Women Development Army (WDA) leaders (AOR = 9.51, 95% CI: 1.49–60.75) were significantly associated with household contact TB screening by HEWs.

Conclusions

Our finding revealed that the proportion of HH contact TB screened by HEWs was low. Therefore, HEWs should routinely visit HHs of index TB cases and provide regular health education to improve contact screening practice. In addition, it is highly recommended to strengthen HEWs regular discussion about TB activities with WDA leaders and TB TTS.

Integrating tuberculosis research with public health infrastructure: Lessons on community engagement from Orizaba, Mexico

Background: The Orizaba Health Region, in Veracruz, Mexico, has hosted the research programme of the Consorcio Mexicano contra la Tuberculosis since 1995. Methods: The objective of this retrospective case study conducted in 2009 was to describe and explain the evolution and outcomes of the stakeholder and community engagement activities of the Consorcio. Recorded interviews and focus groups were coded to identify major themes related to the success of stakeholder and community engagement activities. Results: The Consorcio successfully managed to embed its research program into the local public health infrastructure. This integration was possible because the core research team tailored its engagement strategy to the local context, while focusing on a large spectrum of stakeholders with various positions of authority and responsibility. The overall engagement strategy can be described as a three-pronged endeavor: building a “coalition” with local authorities, nurturing “camaraderie” with community health workers, and striving to be “present” in the lives of community members and participants. Conclusions: The Consorcio’s efforts teach valuable lessons on how to approach stakeholder and community engagement in tuberculosis (TB) research, particularly in developing countries. Furthermore, the health outcomes reveal stakeholder and community engagement as a potentially under-tapped tool to promote disease control.

Treatment of drug-susceptible tuberculosis among people living with human immunodeficiency virus infection: an update

PURPOSE OF REVIEW

The present review describes recent advances in the treatment of drug-susceptible tuberculosis (DS-TB) among people living with human immunodeficiency virus (PLWH).

RECENT FINDINGS

Higher than standard rifampicin doses (>10 mg/kg/day) are well tolerated and have improved sterilizing activity. Standard pyrazinamide doses may result in low drug exposures; modeling reveals that higher doses (>25 mg/kg/day) may be required to reach target levels, although safety is unknown. Four-month fluoroquinolone-containing regimens are not recommended in the 2017 World Health Organization DS-TB treatment guidelines. These guidelines also recommend fixed-dose combination (FDC) therapy over single drug formulations based on patient preference, though FDC is not associated with improved outcomes. Treatment for 6 months is recommended, with an emphasis on expanded antiretroviral therapy (ART) coverage and monitoring for relapse among those not started on ART within 8 weeks of tuberculosis treatment. Directly observed therapy (DOT) is recommended over self-administered therapy, as is daily therapy over intermittent therapy - both are associated with better tuberculosis outcomes.

SUMMARY

Current WHO tuberculosis treatment guidelines recommend 6 months of daily tuberculosis treatment for PLWH who have DS-TB, and timely ART initiation. Higher rifampin and pyrazinamide doses may enhance treatment effectiveness, but safety data are needed. DOT and FDC therapy are recommended.

Adherence interventions and outcomes of tuberculosis treatment: A systematic review and meta-analysis of trials and observational studies

BACKGROUND

Incomplete adherence to tuberculosis (TB) treatment increases the risk of delayed culture conversion with continued transmission in the community, as well as treatment failure, relapse, and development or amplification of drug resistance. We conducted a systematic review and meta-analysis of adherence interventions, including directly observed therapy (DOT), to determine which approaches lead to improved TB treatment outcomes.

METHODS AND FINDINGS

We systematically reviewed Medline as well as the references of published review articles for relevant studies of adherence to multidrug treatment of both drug-susceptible and drug-resistant TB through February 3, 2018. We included randomized controlled trials (RCTs) as well as prospective and retrospective cohort studies (CSs) with an internal or external control group that evaluated any adherence intervention and conducted a meta-analysis of their impact on TB treatment outcomes. Our search identified 7,729 articles, of which 129 met the inclusion criteria for quantitative analysis. Seven adherence categories were identified, including DOT offered by different providers and at various locations, reminders and tracers, incentives and enablers, patient education, digital technologies (short message services [SMSs] via mobile phones and video-observed therapy [VOT]), staff education, and combinations of these interventions. When compared with DOT alone, self-administered therapy (SAT) was associated with lower rates of treatment success (CS: risk ratio [RR] 0.81, 95% CI 0.73-0.89; RCT: RR 0.94, 95% CI 0.89-0.98), adherence (CS: RR 0.83, 95% CI 0.75-0.93), and sputum smear conversion (RCT: RR 0.92, 95% CI 0.87-0.98) as well as higher rates of development of drug resistance (CS: RR 4.19, 95% CI 2.34-7.49). When compared to DOT provided by healthcare providers, DOT provided by family members was associated with a lower rate of adherence (CS: RR 0.86, 95% CI 0.79-0.94). DOT delivery in the community versus at the clinic was associated with a higher rate of treatment success (CS: RR 1.08, 95% CI 1.01-1.15) and sputum conversion at the end of two months (CS: RR 1.05, 95% CI 1.02-1.08) as well as lower rates of treatment failure (CS: RR 0.56, 95% CI 0.33-0.95) and loss to follow-up (CS: RR 0.63, 95% CI 0.40-0.98). Medication monitors improved adherence and treatment success and VOT was comparable with DOT. SMS reminders led to a higher treatment completion rate in one RCT and were associated with higher rates of cure and sputum conversion when used in combination with medication monitors. TB treatment outcomes improved when patient education, healthcare provider education, incentives and enablers, psychological interventions, reminders and tracers, or mobile digital technologies were employed. Our findings are limited by the heterogeneity of the included studies and lack of standardized research methodology on adherence interventions.

CONCLUSION

TB treatment outcomes are improved with the use of adherence interventions, such as patient education and counseling, incentives and enablers, psychological interventions, reminders and tracers, and digital health technologies. Trained healthcare providers as well as community delivery provides patient-centered DOT options that both enhance adherence and improve treatment outcomes as compared to unsupervised, SAT alone.

The feasibility of task-sharing the identification, emergency treatment, and referral for women with pre-eclampsia by community health workers in India

BACKGROUND

Hypertensive disorders are the second highest direct obstetric cause of maternal death after haemorrhage, accounting for 14% of maternal deaths globally. Pregnancy hypertension contributes to maternal deaths, particularly in low- and middle-income countries, due to a scarcity of doctors providing evidence-based emergency obstetric care. Task-sharing some obstetric responsibilities may help to reduce the mortality rates. This study was conducted to assess acceptability by the community and other healthcare providers, for task-sharing by community health workers (CHW) in the identification and initial care in hypertensive disorders in pregnancy.

METHODS

This study was conducted in two districts of Karnataka state in south India. A total of 14 focus group discussions were convened with various community representatives: women of reproductive age (N = 6), male decision-makers (N = 2), female decision-makers (N = 3), and community leaders (N = 3). One-to-one interviews were held with medical officers (N = 2), private healthcare OBGYN specialists (N = 2), senior health administrators (N = 2), Taluka (county) health officers (N = 2), and obstetricians (N = 4). All data collection was facilitated by local researchers familiar with the setting and language. Data were subsequently transcribed, translated and analysed thematically using NVivo 10 software.

RESULTS

There was strong community support for home visits by CHW to measure the blood pressure of pregnant women; however, respondents were concerned about their knowledge, training and effectiveness. The treatment with oral antihypertensive agents and magnesium sulphate in emergencies was accepted by community representatives but medical practitioners and health administrators had reservations, and insisted on emergency transport to a higher facility. The most important barriers for task-sharing were concerns regarding insufficient training, limited availability of medications, the questionable validity of blood pressure devices, and the ability of CHW to correctly diagnose and intervene in cases of hypertensive disorders of pregnancy.

CONCLUSION

Task-sharing to community-based health workers has potential to facilitate early diagnosis of the hypertensive disorders of pregnancy and assist in the provision of emergency care. We identified some facilitators and barriers for successful task-sharing of emergency obstetric care aimed at reducing mortality and morbidity due to hypertensive disorders of pregnancy.

A multi-site community randomized trial of community health workers to provide counseling and support for patients newly entering HIV care in rural Ethiopia: study design and baseline implementation

BACKGROUND

Although HIV therapy is delivered to millions globally, treatment default (especially soon after entering care) remains a challenge. Community health workers (CHWs) can provide many services for people with HIV, including in rural and resource-limited settings.

OBJECTIVES

We designed and implemented a 32 site community randomized trial throughout southern Ethiopia to assess an intervention using CHWs to improve retention in HIV care.

METHODS

Sixteen district hospital and 16 local health center HIV clinics were randomized 1:1 to be intervention or control sites. From each site, we enrolled adults newly entering HIV care. Participants at intervention sites were assigned a CHW who provided: HIV and health education; counseling and social support; and facilitated communication with HIV clinics. All participants are followed through three years with annual health surveys, plus HIV clinic record abstraction including clinic visit dates. CHWs record operational data about their client contacts.

RESULTS

1799 HIV patients meeting inclusion criteria were enrolled and randomized: 59% were female, median age = 32 years, median CD4 + count = 263 cells/mm³, and 41% were WHO Stage III or IV. A major enrollment challenge was fewer new HIV patients initiating care at participating sites due to shortage of HIV test kits. At intervention sites, 71 CHWs were hired, trained and assigned to clients. In meeting with clients, CHWs needed to accommodate to various challenges, including HIV stigma, distance, and clients lacking cell phones.

CONCLUSIONS

This randomized community HIV trial using CHWs in a resource-limited setting was successfully launched, but required flexibility to adapt to unforeseen challenges.

Home Based Care as an Approach to Improve the Efficiency of treatment for MDR Tuberculosis: A Quasi-Experimental Pilot Study

INTRODUCTION

Multi Drug Resistant Tuberculosis (MDR TB) has emerged as a significant public health problem in India. The prolonged treatment duration in MDR TB is a challenge in achieving treatment completion and poses a threat to TB control in the country. Home based care is an approach accepted by patients because it helps in ameliorating their understanding of TB, improving the compliance and reducing stigma in the community.

AIM

To assess the outcome of Home-Based Care (HC) versus No Home-Based Care (NHC) on the treatment of MDR TB patients registered at two chest clinics in Eastern Delhi.

MATERIALS AND METHODS

A quasi-experimental study was done among diagnosed MDR TB patients receiving Category IV regimen under Revised National Tuberculosis Control Programme (RNTCP) from two government chest clinics in Eastern Delhi during May 2014 to May 2016. In the control arm, 50 MDR TB patients at one of the chest clinics were offered the standard Category IV regimen under RNTCP; while in the intervention arm, 50 MDR TB patients at the second chest clinic were provided home based care (counselling, support for completion of treatment, rehabilitation, and nutritional support) along with the standard treatment. The primary outcome assessed was outcome of treatment, while secondary outcomes included stigma faced due to the disease, and impact of disease on family and community life.

RESULTS

The primary outcome data was available for 32 (64%) participants in the intervention arm, and 38 (76%) participants in control arm. The treatment was significantly more successful in the intervention arm (p<0.03). The data on secondary outcomes was available for all participants. Stigma due to disease was significantly lower in the intervention arm (p<0.01); also rejection faced by participants from family and community due to disease was significantly lower among the HC group (p<0.05).

CONCLUSION

Home-based care in MDR TB treatment holds potential in improving treatment outcomes of patient.

Adherence to anti-tuberculosis treatment in Tigray, Northern Ethiopia

SETTING

Tuberculosis (TB) patients in Mekelle Zone, Tigray Region, in Ethiopia.

OBJECTIVE

To investigate adherence to anti-tuberculosis treatment.

DESIGN

A cross-sectional study in health facilities providing anti-tuberculosis treatment was conducted. Adherence was measured in three ways: through self-reported missed doses, by visual analogue scale whereby patients rate their own adherence and by record review. A patient was considered to be adherent if 90% or more of the prescribed medication was taken.

RESULT

Of 278 TB patients included, 101 were in the intensive and 177 in the continuation phase. Respectively 67 (24.1%), 130 (46.8%) and 80 (28.8%) patients had smear-positive, smear-negative and extra-pulmonary TB. Self-report of missed doses and record review indicated adherence of respectively 273 (97.3%) and 271 (97.5%) patients. By visual analogue scale, 250 (91.6%) patients rated themselves as adherent. History of drug side effects (aOR 0.25, 95%CI 0.08-0.77) and knowledge about TB prevention (aOR 0.19, 95%CI 0.05-0.8) were independently associated with being adherent in this setting.

CONCLUSION

Adherence to anti-tuberculosis treatment was high in our study. Adherence support should be given to the poor, the elderly, patients co-infected with the human immunodeficiency virus, alcohol abusers and smokers. Health education on TB prevention should be given to all TB patients regularly.

Interventions to improve adherence to treatment for paediatric tuberculosis in low- and middle-income countries: a systematic review and meta-analysis

Objective

To assess the design, delivery and outcomes of interventions to improve adherence to treatment for paediatric tuberculosis in low- and middle-income countries and develop a contextual framework for such interventions.

Methods

We searched PubMed and Cochrane databases for reports published between 1 January 2003 and 1 December 2013 on interventions to improve adherence to treatment for tuberculosis that included patients younger than 20 years who lived in a low- or middle-income country. For potentially relevant articles that lacked paediatric outcomes, we contacted the authors of the studies. We assessed heterogeneity and risk of bias. To evaluate treatment success – i.e. the combination of treatment completion and cure – we performed random-effects meta-analysis. We identified areas of need for improved intervention practices.

Findings

We included 15 studies in 11 countries for the qualitative analysis and of these studies, 11 qualified for the meta-analysis – representing 1279 children. Of the interventions described in the 15 studies, two focused on education, one on psychosocial support, seven on care delivery, four on health systems and one on financial provisions. The children in intervention arms had higher rates of treatment success, compared with those in control groups (odds ratio: 3.02; 95% confidence interval: 2.19–4.15). Using the results of our analyses, we developed a framework around factors that promoted or threatened treatment completion.

Conclusion

Various interventions to improve adherence to treatment for paediatric tuberculosis appear both feasible and effective in low- and middle-income countries.