Repairing boundaries along pathways to tuberculosis case detection: a qualitative synthesis of intervention designs

BACKGROUND

Tuberculosis case-finding interventions often involve several activities to enhance patient pathways, and it is unclear which activity defines the type of case-finding intervention. When conducting studies to identify the most effective case-finding intervention it is important to have a clear understanding of these interventions for meaningful comparisons. This review aimed to construct a systems-based logic model of all pathways to tuberculosis case detection through a synthesis of intervention designs.

METHODS

We identified an existing systematic review on the effectiveness of interventions to increase tuberculosis case detection and updated the search from December 2016 to October 2020. We included randomized controlled trials, as these designs encourage detailed description of interventions. Taking each study in turn, intervention descriptions were read in detail. The texts were analysed qualitatively by constantly comparing emerging codes to construct patient journeys, visualized as logical chains. Actions taken as part of interventions were positioned along patient journeys to theorize the sequence of outcomes. Patient journeys formed the basis of the model, which was refined through discussion.

RESULTS

Based on intervention descriptions from 17 randomized controlled trials, our model distinguishes two care-seeking pathways and four screening pathways. An open invitation to people with tuberculosis symptoms creates care-seeking pathways. On care-seeking pathways, systematic screening can be conducted at general health services, but not at specific TB care services. People invited to tuberculosis services regardless of symptoms follow tuberculosis screening pathways and may be identified with presumptive tuberculosis even if they do not seek care for tuberculosis symptoms. Tuberculosis screening pathways include screening offered to all people accessing care at general health services, screening at a mobile clinic or health facility with open invitation to a whole population or tuberculosis contacts, screening personally offered to a whole population or tuberculosis contacts at home, work or school, and screening offered to people receiving care for human immunodeficiency virus or other clinical risk-group care.

CONCLUSION

This systems-based logic model of tuberculosis case-finding pathways may support standardized terminology, consistency, transparency and improved communication among researchers, policy-makers, health workers and community members when implementing and evaluating interventions to improve tuberculosis case detection.

Missed opportunities in tuberculosis investigation and associated factors at public health facilities in Uganda

Background

The incidence of tuberculosis (TB) is high in Uganda; yet, TB case detection is low. The population-based survey on the prevalence of TB in Uganda revealed that only 16% of presumptive TB patients seeking care at health facilities were offered sputum microscopy or chest-X ray (CXR). This study aimed to determine the magnitude of, and patient factors associated with missed opportunities in TB investigation at public health facilities of Wakiso District in Uganda.

Methods

A facility-based cross-sectional survey was conducted at 10 high volume public health facilities offering comprehensive TB services in Wakiso, Uganda, among adults (≥18 years) with at least one symptom suggestive of TB predefined according to the World Health Organisation criteria. Using exit interviews, data on demographics, TB symptoms, and clinical data relevant to TB diagnosis were collected. A missed opportunity in TB investigation was defined as a patient with symptoms suggestive of TB who did not have sputum and/or CXR evaluation to rule out TB. Poisson regression analysis was performed to determine factors associated with missed opportunities in TB investigation.

Results

Two hundred forty-seven (247) patients with presumptive TB exiting at antiretroviral therapy (ART) clinics (n = 132) or general outpatient clinics (n = 115) at public health facilities were recruited into this study. Majority of participants were female (161/247, 65.2%) with a mean + SD age of 35.1 + 11.5 years. Overall, 138 (55.9%) patients with symptoms suggestive of TB disease did not have sputum and/or CXR examinations. Patients who did not inform health workers about their TB related symptoms were more likely to miss a TB investigation (adjusted prevalence ratio (aPR): 1.68, 95%CI; 1.36–2.08, P < 0.001). However, patients who reported duration of cough of 2 weeks or more were less likely to be missed for TB screening (aPR; 0.69, 95%CI; 0.56–0.86, p < 0.001).

Conclusion

There are substantial missed opportunities for TB diagnosis in Wakiso District. While it is important that patients should be empowered to report symptoms, health workers need to proactively implement the WHO TB symptom screen tool and complete the subsequent steps in the TB diagnostic cascade.

Factors associated with tuberculosis diagnosis and treatment delays in Middle East and North Africa: a systematic review

Background

Political instability, economic sanctions and substandard quality of health care negatively affect tuberculosis (TB) control in the Middle East and North Africa (MENA) region.

Aims

We aimed to elucidate factors contributing to delays in TB diagnosis and treatment in MENA countries.

Methods

Two reviewers independently appraised eligible articles identified through comprehensive searching and extracted data which were subjected to meta-analysis.

Results

Delays in TB diagnosis were associated with older age and low income [(OR = 1.49; 95% CI: 1.31-1.70) and (OR = 1.26; 95% CI: 1.09-1.45)] respectively (n = 17 studies). Being female was associated with patient delay and health system delay [(OR = 1.24; 95% CI: 1.02-1.50) and (OR = 1.68; 95% CI: 1.18-2.38)] respectively. Knowledge and perception of TB, having employment and low levels of crowding were each protective against patient delay. The GRADE system rated the evidence as of low quality.

Conclusion

This review provides evidence for facilitators and barriers to TB diagnosis and health system delays. For successful TB control in the MENA region, TB awareness and interventions targeting the elderly and those from lower-income settings, particularly directed at gender differences, are essential.

Training of community healthcare providers and TB case detection in Bangladesh

BACKGROUND

For several years, BRAC (previously known as the Bangladesh Rural Advancement Committee) has been assisting with national TB control efforts in Bangladesh and has especially focused on training of community healthcare personnel. This study attempts to determine whether there is any association between a community-based TB training programme in peri-urban Dhaka and TB case finding within the same catchment area.

METHODS

This was a cross-sectional retrospective study using laboratory sputum registers and annual BRAC training reports.

RESULTS

Between 2005 and 2010, there were 536 training activities for community healthcare providers with 9037 people trained. Numbers of patients attending laboratories with suspected TB increased from 8211 in 2004 (before training) to 10 961 in 2005 (start of training) with the proportion diagnosed with smear-positive TB increasing from 7.1% to 11.2%. Thereafter, the numbers with suspected and diagnosed TB remained similar up to 2010. The most important sources of referral of patients for investigation were community health volunteers and self-referring patients accounting for 58% of all patients.

CONCLUSION

In this operational research study in peri-urban Dhaka, there was an initial increase in TB case finding with numbers then reaching a plateau despite continued training activities. Further prospective evaluation is required to understand these phenomena.