Durations and Delays in Care Seeking,Diagnosis and Treatment Initiation in Uncomplicated Pulmonary Tuberculosis Patients in Mumbai,India

BackgroundTimely diagnosis and treatment initiation are critical to reduce the chain of transmission of Tuberculosis (TB) in places like Mumbai, where almost 60% of the inhabitants reside in overcrowded slums. This study documents the pathway from the onset of symptoms suggestive of TB to initiation of TB treatment and examines factors responsible for delay among uncomplicated pulmonary TB patients in Mumbai.MethodsA population-based retrospective survey was conducted in the slums of 15 high TB burden administrative wards to identify 153 self-reported TB patients. Subsequently in-depth interviews of 76 consenting patients that fit the inclusion criteria were undertaken using an open-ended interview schedule. Mean total, first care seeking, diagnosis and treatment initiation duration and delays were computed for new and retreatment patients. Patients showing defined delays were divided into outliers and non-outliers for all three delays using the median values.ResultsThe mean duration for the total pathway was 65 days with 29% of patients being outliers. Importantly the mean duration of first care seeking was similar in new (24 days) and retreatment patients (25 days). Diagnostic duration contributed to 55% of the total pathway largely in new patients. Treatment initiation was noted to be the least among the three durations with mean duration in retreatment patients twice that of new patients. Significantly more female patients experienced diagnostic delay. Major shift of patients from the private to public sector and non-allopaths to allopaths was observed, particularly for treatment initiation.ConclusionAchieving positive behavioural changes in providers (especially non-allopaths) and patients needs to be considered in TB control strategies. Specific attention is required in counselling of TB patients so that timely care seeking is effected at the time of relapse. Prioritizing improvement of environmental health in vulnerable locations and provision of point of care diagnostics would be singularly effective in curbing pathway delays.     

“They Know,They Agree,but They Don’t Do”- The Paradox of Tuberculosis Case Notification by Private Practitioners in Alappuzha District,Kerala, India

Background

Despite being a recognized standard of tuberculosis (TB) care internationally, mandatory TB case notification brings forth challenges from the private sector. Only three TB cases were notified in 2013 by private practitioners compared to 2000 TB cases notified yearly from the public sector in Alappuzha district. The study objective was to explore the knowledge, opinion and barriers regarding TB Notification among private practitioners offering TB services in Alappuzha, Kerala state, India.

Methods & Findings

This was a mixed-methods study with quantitative (survey) and qualitative components conducted between December 2013 and July 2014. The survey, using a structured questionnaire, among 169 private practitioners revealed that 88% were aware of mandatory notification. All patient-related details requested in the notification form (except government-issued identification number) were perceived to be important and easy to provide by more than 80% of practitioners. While more than 95% felt that notification should be mandatory, punitive action in case of failure to notify was considered unnecessary by almost two third. General practitioners (98%) were more likely to be aware of notification than specialists (84 %). (P<0.01). Qualitative purposive personal interviews (n=34) were carried out among private practitioners and public health providers. On thematic framework analysis of the responses, barriers to TB notification were grouped into three themes: ‘private provider misconceptions about notification’, ‘patient confidentiality, and stigma and discrimination ’and ‘lack of cohesion and coordination between public and private sector’. Private practitioners did not consider it necessary to notify TB cases treated with daily regimen.

Conclusion

Communication strategies like training, timely dissemination of information of policy changes and one-to-one dialogue with private practitioners to dispel misconceptions may enhance TB notification. Trust building strategies like providing feedback about referred cases from private sector, health personnel visit or a liaison private doctor may ensure compliance to public health activities.     

Evaluating the impact of the nationwide public–private mix (PPM) program for tuberculosis under National Health Insurance in South Korea: A difference in differences analysis

BackgroundPublic–private mix (PPM) programs on tuberculosis (TB) have a critical role in engaging and integrating the private sector into the national TB control efforts in order to meet the End TB Strategy targets. South Korea’s PPM program can provide important insights on the long-term impact and policy gaps in the development and expansion of PPM as a nationwide program.Methods and findingsHealthcare is privatized in South Korea, and a majority (80.3% in 2009) of TB patients sought care in the private sector. Since 2009, South Korea has rapidly expanded its PPM program coverage under the National Health Insurance (NHI) scheme as a formal national program with dedicated PPM nurses managing TB patients in both the private and public sectors. Using the difference in differences (DID) analytic framework, we compared relative changes in TB treatment outcomes—treatment success (TS) and loss to follow-up (LTFU)—in the private and public sector between the 2009 and 2014 TB patient cohorts. Propensity score matching (PSM) using the kernel method was done to adjust for imbalances in the covariates between the 2 population cohorts. The 2009 cohort included 6,195 (63.0% male, 37.0% female; mean age: 42.1) and 27,396 (56.1% male, 43.9% female; mean age: 45.7) TB patients in the public and private sectors, respectively. The 2014 cohort included 2,803 (63.2% male, 36.8% female; mean age: 50.1) and 29,988 (56.5% male, 43.5% female; mean age: 54.7) patients. In both the private and public sectors, the proportion of patients with transfer history decreased (public: 23.8% to 21.7% and private: 20.8% to 17.6%), and bacteriological confirmed disease increased (public: 48.9% to 62.3% and private: 48.8% to 58.1%) in 2014 compared to 2009. After expanding nationwide PPM, absolute TS rates improved by 9.10% (87.5% to 93.4%) and by 13.6% (from 70.3% to 83.9%) in the public and private sectors. Relative to the public, the private saw 4.1% (95% confidence interval [CI] 2.9% to 5.3%, p-value < 0.001) and −8.7% (95% CI −9.7% to −7.7%, p-value <0.001) higher rates of improvement in TS and reduction in LTFU. Treatment outcomes did not improve in patients who experienced at least 1 transfer during their TB treatment. Study limitations include non-longitudinal nature of our original dataset, inability to assess the regional disparities, and verify PPM program’s impact on TB mortality.ConclusionsWe found that the nationwide scale-up of the PPM program was associated with improvements in TB treatment outcomes in the private sector in South Korea. Centralized financial governance and regulatory mechanisms were integral in facilitating the integration of highly diverse South Korean private sector into the national TB control program and scaling up of the PPM intervention nationwide. However, TB care gaps continued to exist for patients who transferred at least once during their treatment. These programmatic gaps may be improved through reducing administrative hurdles and making programmatic amendments that can help facilitate management TB patients between institutions and healthcare sectors, as well as across administrative regions.

Sarah Yu and co-workers study population-level provision of tuberculosis care and outcomes in South Korea.     

Crises and Resilience at the Frontline—Public Health Facility Managers under Devolution in a Sub-County on the Kenyan Coast

Background

Public primary health care (PHC) facilities are for many individuals the first point of contact with the formal health care system. These facilities are managed by professional nurses or clinical officers who are recognised to play a key role in implementing health sector reforms and facilitating initiatives aimed at strengthening community involvement. Little in-depth research exists about the dimensions and challenges of these managers’ jobs, or on the impact of decentralisation on their roles and responsibilities. In this paper, we describe the roles and responsibilities of PHC managers–or ‘in-charges’ in Kenya, and their challenges and coping strategies, under accelerated devolution.

Methods

The data presented in this paper is part of a wider set of activities aimed at understanding governance changes under devolution in Kenya, under the umbrella of a ‘learning site’. A learning site is a long term process of collaboration between health managers and researchers deciding together on key health system questions and interventions. Data were collected through seven formal in depth interviews and observations at four PHC facilities as well as eight in depth interviews and informal interactions with sub-county managers from June 2013 to July 2014. Drawing on the Aragon framework of organisation capacity we discuss the multiple accountabilities, daily routines, challenges and coping strategies among PHC facility managers.

Results

PHC in-charges perform complex and diverse roles in a difficult environment with relatively little formal preparation. Their key concerns are lack of job clarity and preparedness, the difficulty of balancing multidirectional accountability responsibilities amidst significant resource shortages, and remuneration anxieties. We show that day-to-day management in an environment of resource constraints and uncertainty requires PHC in-charges who are resilient, reflective, and continuously able to learn and adapt. We highlight the importance of leadership development including the building of critical soft skills such as relationship building.     

The potential impact of urine-LAM diagnostics on tuberculosis incidence and mortality: A modelling analysis

BackgroundLateral flow urine lipoarabinomannan (LAM) tests could offer important new opportunities for the early detection of tuberculosis (TB). The currently licensed LAM test, Alere Determine TB LAM Ag (‘LF-LAM’), performs best in the sickest people living with HIV (PLHIV). However, the technology continues to improve, with newer LAM tests, such as Fujifilm SILVAMP TB LAM (‘SILVAMP-LAM’) showing improved sensitivity, including amongst HIV-negative patients. It is important to anticipate the epidemiological impact that current and future LAM tests may have on TB incidence and mortality.Methods and findingsConcentrating on South Africa, we examined the impact that widening LAM test eligibility would have on TB incidence and mortality. We developed a mathematical model of TB transmission to project the impact of LAM tests, distinguishing ‘current’ tests (with sensitivity consistent with LF-LAM), from hypothetical ‘future’ tests (having sensitivity consistent with SILVAMP-LAM). We modelled the impact of both tests, assuming full adoption of the 2019 WHO guidelines for the use of these tests amongst those receiving HIV care. We also simulated the hypothetical deployment of future LAM tests for all people presenting to care with TB symptoms, not restricted to PLHIV. Our model projects that 2,700,000 (95% credible interval [CrI] 2,000,000–3,600,000) and 420,000 (95% CrI 350,000–520,000) cumulative TB incident cases and deaths, respectively, would occur between 2020 and 2035 if the status quo is maintained. Relative to this comparator, current and future LAM tests would respectively avert 54 (95% CrI 33–86) and 90 (95% CrI 55–145) TB deaths amongst inpatients between 2020 and 2035, i.e., reductions of 5% (95% CrI 4%–6%) and 9% (95% CrI 7%–11%) in inpatient TB mortality. This impact in absolute deaths averted doubles if testing is expanded to include outpatients, yet remains <1% of country-level TB deaths. Similar patterns apply to incidence results. However, deploying a future LAM test for all people presenting to care with TB symptoms would avert 470,000 (95% CrI 220,000–870,000) incident TB cases (18% reduction, 95% CrI 9%–29%) and 120,000 (95% CrI 69,000–210,000) deaths (30% reduction, 95% CrI 18%–44%) between 2020 and 2035. Notably, this increase in impact arises largely from diagnosis of TB amongst those with HIV who are not yet in HIV care, and who would thus be ineligible for a LAM test under current guidelines. Qualitatively similar results apply under an alternative comparator assuming expanded use of GeneXpert MTB/RIF (‘Xpert’) for TB diagnosis. Sensitivity analysis demonstrates qualitatively similar results in a setting like Kenya, which also has a generalised HIV epidemic, but a lower burden of HIV/TB coinfection. Amongst limitations of this analysis, we do not address the cost or cost-effectiveness of future tests. Our model neglects drug resistance and focuses on the country-level epidemic, thus ignoring subnational variations in HIV and TB burden.ConclusionsThese results suggest that LAM tests could have an important effect in averting TB deaths amongst PLHIV with advanced disease. However, achieving population-level impact on the TB epidemic, even in high-HIV-burden settings, will require future LAM tests to have sufficient performance to be deployed more broadly than in HIV care.

Saskia Ricks and colleagues model the impact of urine-LAM diagnostics for reducing tuberculosis incidence, across different implementation scenarios.     

Tuberculosis in Migrant Populations. A Systematic Review of the Qualitative Literature

Background

The re-emergence of tuberculosis (TB) in low-incidence countries and its disproportionate burden on immigrants is a public health concern posing specific social and ethical challenges. This review explores perceptions, knowledge, attitudes and treatment adherence behaviour relating to TB and their social implications as reported in the qualitative literature.

Methods

Systematic review in four electronic databases. Findings from thirty selected studies extracted, tabulated, compared and synthesized.

Findings

TB was attributed to many non-exclusive causes including air-born transmission of bacteria, genetics, malnutrition, excessive work, irresponsible lifestyles, casual contact with infected persons or objects; and exposure to low temperatures, dirt, stress and witchcraft. Perceived as curable but potentially lethal and highly contagious, there was confusion around a condition surrounded by fears. A range of economic, legislative, cultural, social and health system barriers could delay treatment seeking. Fears of deportation and having contacts traced could prevent individuals from seeking medical assistance. Once on treatment, family support and “the personal touch” of health providers emerged as key factors facilitating adherence. The concept of latent infection was difficult to comprehend and while TB screening was often seen as a socially responsible act, it could be perceived as discriminatory. Immigration and the infectiousness of TB mutually reinforced each another exacerbating stigma. This was further aggravated by indirect costs such as losing a job, being evicted by a landlord or not being able to attend school.

Conclusions

Understanding immigrants’ views of TB and the obstacles that they face when accessing the health system and adhering to a treatment programme-taking into consideration their previous experiences at countries of origin as well as the social, economic and legislative context in which they live at host countries- has an important role and should be considered in the design, evaluation and adaptation of programmes.     

Total Delay in Treatment among Smear Positive Pulmonary Tuberculosis Patients in Five Primary Health Centers,Southern Ethiopia: A Cross Sectional Study

Introduction

The global burden of Tuberculosis (TB) remains enormous. Delay in TB diagnosis may lead to a higher infectious pool in the community and a more advanced disease state at presentation increasing the risk of mortality. This study is conducted to determine the total delay before treatment among smear positive Pulmonary Tuberculosis (PTB) patients.

Methods

A health institution based cross sectional study was conducted in five primary health centers in southern Ethiopia from June to December 2012. A total of 328 smear positive PTB patients were enrolled in the study. A structured and pre-tested questionnaire was used. Median patient, diagnostic, and treatment delays were calculated to determine the total delay. Multiple logistic regression analysis was used to identify factors associated with total delay.

Results

The median patient, diagnostic, treatment and total delays measured in days were 30 (IQR 20.2, 60), 7 (IQR: 3, 14), 3 (IQR: 1, 4) and 45 (IQR: 34.5, 69.5) days respectively. Patients for whom treatment was not initiated within 45 days of onset of symptom(s) (total delay) constituted 49% of the study participants (59.5% among males and 39.2% among females; P<0.001). Total delay was found to be associated with: being female [AOR  = 0.34, 95% CI: 0.18–0.62], having attended tertiary level education [AOR  = 0.11, 95% CI: 0.02–0.55], perceived severity of stigma during the current TB disease course [AOR = 2. 18, 95% CI: 1.07, 4.42] and living in houses with higher family size [AOR = 0.26, 95% CI: 0.11, 0.61].

Conclusion

Total delay in treatment of TB is still high in the study area. Patient''s sex, perceived stigma, educational status and family size are significantly contributing for total delay. Therefore, a concerted effort should be taken in order to improve health seeking behavior of the community on TB and to reduce delays from seeking care after experiencing TB symptoms.     

Effectiveness of a brief group behavioral intervention for common mental disorders in Syrian refugees in Jordan: A randomized controlled trial

BackgroundCommon mental disorders are frequently experienced by refugees. This study evaluates the impact of a brief, lay provider delivered group-based psychological intervention [Group Problem Management Plus (gPM+)] on the mental health of refugees in a camp, as well as on parenting behavior and children’s mental health.Methods and findingsIn this single-blind, parallel, randomized controlled trial, 410 adult Syrian refugees (300 females, 110 males) in Azraq Refugee Camp (Jordan) were identified through screening of psychological distress (≥16 on the Kessler Psychological Distress Scale) and impaired functioning (≥17 on the WHO Disability Assessment Schedule). Participants were randomly allocated to gPM+ or enhanced usual care (EUC) involving referral information for psychosocial services on a 1:1 ratio. Participants were aware of treatment allocation, but assessors were blinded to treatment condition. Primary outcomes were scores on the Hopkins Symptom Checklist-25 (HSCL; depression and anxiety scales) assessed at baseline, 6 weeks, and 3 months follow-up as the primary outcome time point. It was hypothesized that gPM+ would result in greater reductions of scores on the HSCL than EUC. Secondary outcomes were disability, posttraumatic stress, personally identified problems, prolonged grief, prodromal psychotic symptoms, parenting behavior, and children’s mental health. Between October 15, 2019 and March 2, 2020, 624 refugees were screened for eligibility, 462 (74.0%) screened positive, of whom 204 were assigned to gPM+ and 206 to EUC. There were 168 (82.4%) participants in gPM+ and 189 (91.7%) in EUC assessed at follow-up. Intent-to-treat analyses indicated that at follow-up, participants in gPM+ showed greater reduction on HSCL depression scale than those receiving EUC (mean difference, 3.69 [95% CI 1.90 to 5.48], p = .001; effect size, 0.40). There was no difference between conditions in anxiety (mean difference −0.56, 95% CI −2.09 to 0.96; p = .47; effect size, −0.03). Relative to EUC, participants in gPM+ had greater reductions in severity of personally identified problems (mean difference 0.88, 95% CI 0.07 to 1.69; p = .03), and inconsistent disciplinary parenting (mean difference 1.54, 95% CI 1.03 to 2.05; p < .001). There were no significant differences between conditions for changes in PTSD, disability, grief, prodromal symptoms, or childhood mental health outcomes. Mediation analysis indicated the change in inconsistent disciplinary parenting was associated with reduced attentional (β = 0.11, SE .07; 95% CI .003 to .274) and internalizing (β = 0.08, SE .05; 95% CI .003 to 0.19) problems in children. No adverse events were attributable to the interventions or the trial. Major limitations included only one-quarter of participants being male, and measures of personally identified problems, grief, prodromal psychotic symptoms, inconsistent parenting behavior, and children’s mental health have not been validated with Syrians.ConclusionsIn camp-based Syrian refugees, a brief group behavioral intervention led to reduced depressive symptoms, personally identified problems, and disciplinary parenting compared to usual care, and this may have indirect benefits for refugees’ children. The limited capacity of the intervention to reduce PTSD, disability, or children’s psychological problems points to the need for development of more effective treatments for refugees in camp settings.Trial registrationProspectively registered at Australian and New Zealand Clinical Trials Registry: ACTRN12619001386123.

Richard A. Bryant and colleagues evaluate effects of a lay provider-delivered intervention on adult Syrian refugees’ mental health, parenting behavior, and their children’s mental health.     

Care Seeking Behaviour for Children with Suspected Pneumonia in Countries in Sub-Saharan Africa with High Pneumonia Mortality

Pneumonia is the leading cause of childhood mortality in sub-Saharan Africa (SSA). Because effective antibiotic treatment exists, timely recognition of pneumonia and subsequent care seeking for treatment can prevent deaths. For six high pneumonia mortality countries in SSA we examined if children with suspected pneumonia were taken for care, and if so, from which type of care providers, using national survey data of 76530 children. We also assessed factors independently associated with care seeking from health providers, also known as ‘appropriate’ providers. We report important differences in care seeking patterns across these countries. In Tanzania 85% of children with suspected pneumonia were taken for care, whereas this was only 30% in Ethiopia. Most of the children living in these six countries were taken to a primary health care facility; 86, 68 and 59% in Ethiopia, Tanzania and Burkina Faso respectively. In Uganda, hospital care was sought for 60% of children. 16–18% of children were taken to a private pharmacy in Democratic Republic of Congo (DRC), Tanzania and Nigeria. In Tanzania, children from the richest households were 9.5 times (CI 2.3–39.3) more likely to be brought for care than children from the poorest households, after controlling for the child’s age, sex, caregiver’s education and urban-rural residence. The influence of the age of a child, when controlling for sex, urban-rural residence, education and wealth, shows that the youngest children (<2 years) were more likely to be brought to a care provider in Nigeria, Ethiopia and DRC. Urban-rural residence was not significantly associated with care seeking, after controlling for the age and sex of the child, caregivers education and wealth. The study suggests that it is crucial to understand country-specific care seeking patterns for children with suspected pneumonia and related determinants using available data prior to planning programmatic responses.     

Care Seeking Behavior of Chest Symptomatics: A Community Based Study Done in South India after the Implementation of the RNTCP

Introduction

With the creation of the Revised National TB Control Programme (RNTCP), tuberculosis services have become decentralized and more accessible. A 1997 study prior to RNTCP implementation reported that most chest symptomatics accessed first private health care facilities and a general dissatisfaction with government health facilities. The study was repeated post-RNTCP implementation to gain insight into the current care seeking behavior of chest symptomatics.

Methodology

A cross-sectional community-based study carried out between March-August 2008 in 4 sites (2 rural [R] and 2 urban [U]) from the same two districts of Chennai and Madurai, southern India, as in the 1997 study. Six hundred and forty chest symptomatics were identified (R 314; U 326), and detailed interviews were done for 606 (R311; U295).

Results

Prevalence of chest symptomatics in the urban and rural areas were 2.7% and 4.9% respectively (p<0.01), and was found to increase with age (Chi-square for trend, p<0.01). Longer delays in seeking care were seen amongst symptomatics above 45 years of age (p 0.01), and those who had taken previous TB treatment (p = 0.05). Overall, 50% (222/444) of the chest symptomatics approached a government health care facility first (R 142 (61%); U 80 (38%), p = <0.001). This was significantly (p<0.001) more than were observed in the 1997 study, where only 38.4% approached a government facility first. Sixty two (28%) of the 222 made a second visit to a government facility (R26%; U31%), while 17% shifted to a private facility (R14%; U21%). Dissatisfaction with the health care facility was one of the major reasons expressed.

Conclusions

It appears that the RNTCP has had an impact in the community with regard to the availability and accessibility of TB services in government health facilities. However the relatively high levels of subsequent shifting to private health facilities calls for urgent action to make government facilities more patients friendly with quality care facilities in the delivery of RNTCP services.     

Missed Opportunities for TB Investigation in Primary Care Clinics in South Africa: Experience from the XTEND Trial

Setting

40 primary health clinics (PHCs) in four provinces in South Africa, June 2012 –February 2013.

Objective

To determine whether health care worker (HCW) practice in investigating people with TB symptoms was altered when the initial test for TB was changed from smear microscopy to Xpert MTB/RIF.

Design

Cross-sectional substudy at clinics participating in a pragmatic cluster randomised trial, Xpert for TB: Evaluating a New Diagnostic "XTEND", which evaluated the effect of Xpert MTB/RIF implementation in South Africa.

Methods

Consecutive adults exiting PHCs reporting at least one TB symptom (defined as any of cough, weight loss, night sweats and fever) were enrolled. The main outcome was the proportion who self-reported having sputum requested by HCW during the clinic encounter just completed.

Results

3604 adults exiting PHCs (1676 in Xpert arm, 1928 in microscopy arm) were enrolled (median age 38 years, 71.4% female, 38.8% reported being HIV-positive, 70% reported cough). For 1267 participants (35.2%) the main reason for attending the clinic was TB symptom(s).Overall 2130/3604 (59.1%) said they reported their symptom(s) to HCW. 22.7% (818/3604) reported having been asked to give sputum for TB investigation. Though participants in the Xpert vs. microscopy arm were more likely to have sputum requested by HCW, this was not significantly different: overall (26.0% [436/1676] vs 19.8% [382/1928]; adjusted prevalence ratio [aPR] 1.31, [95% CI 0.78–2.20]) and when restricted to those presenting at clinics due to symptoms (49.1% [260/530] vs 29.9% [220/737]; aPR 1.38 [0.89–2.13]) and those reporting being HIV-positive (29.4% [190/647] vs 20.8% [156/749]; aPR 1.38[0.88–2.16]).Those attending clinic due to TB symptoms, were more likely to have sputum requested if they had increasing number of symptoms; longer duration of cough, unintentional weight loss and night sweats and if they reported symptoms to HCW.

Conclusions

A large proportion of people exiting PHCs reporting TB symptoms did not get tested. Implementation of Xpert MTB/RIF did not substantially change the probability of testing for TB. Better systems are needed to ensure that opportunities to identify active TB among PHC attendees are not missed.     

Effect of Removing Direct Payment for Health Care on Utilisation and Health Outcomes in Ghanaian Children: A Randomised Controlled Trial

Background

Delays in accessing care for malaria and other diseases can lead to disease progression, and user fees are a known barrier to accessing health care. Governments are introducing free health care to improve health outcomes. Free health care affects treatment seeking, and it is therefore assumed to lead to improved health outcomes, but there is no direct trial evidence of the impact of removing out-of-pocket payments on health outcomes in developing countries. This trial was designed to test the impact of free health care on health outcomes directly.

Methods and Findings

2,194 households containing 2,592 Ghanaian children under 5 y old were randomised into a prepayment scheme allowing free primary care including drugs, or to a control group whose families paid user fees for health care (normal practice); 165 children whose families had previously paid to enrol in the prepayment scheme formed an observational arm. The primary outcome was moderate anaemia (haemoglobin [Hb] < 8 g/dl); major secondary outcomes were health care utilisation, severe anaemia, and mortality. At baseline the randomised groups were similar. Introducing free primary health care altered the health care seeking behaviour of households; those randomised to the intervention arm used formal health care more and nonformal care less than the control group. Introducing free primary health care did not lead to any measurable difference in any health outcome. The primary outcome of moderate anaemia was detected in 37 (3.1%) children in the control and 36 children (3.2%) in the intervention arm (adjusted odds ratio 1.05, 95% confidence interval 0.66–1.67). There were four deaths in the control and five in the intervention group. Mean Hb concentration, severe anaemia, parasite prevalence, and anthropometric measurements were similar in each group. Families who previously self-enrolled in the prepayment scheme were significantly less poor, had better health measures, and used services more frequently than those in the randomised group.

Conclusions

In the study setting, removing out-of-pocket payments for health care had an impact on health care-seeking behaviour but not on the health outcomes measured.Trial registration: ClinicalTrials.gov (#{"type":"clinical-trial","attrs":{"text":"NCT00146692","term_id":"NCT00146692"}}NCT00146692).     

The Global Health Impact Index: Promoting Global Health

Millions of people cannot access essential medicines they need for deadly diseases like malaria, tuberculosis (TB) and HIV/AIDS. There is good information on the need for drugs for these diseases but until now, no global estimate of the impact drugs are having on this burden. This paper presents a model measuring companies’ key malaria, TB and HIV/AIDS drugs’ consequences for global health (global-health-impact.org). It aggregates drugs’ impacts in several ways–by disease, country and originator-company. The methodology can be extended across diseases as well as drugs to provide a more extensive picture of the impact companies’ drugs are having on the global burden of disease. The study suggests that key malaria, TB and HIV/AIDS drugs are, together, ameliorating about 37% of the global burden of these diseases and Sanofi, Novartis, and Pfizer’s drugs are having the largest effect on this burden. Moreover, drug impacts vary widely across countries. This index provides important information for policy makers, pharmaceutical companies, countries, and other stake-holders that can help increase access to essential medicines.     

"Carrying Ibuprofen in the Bag": Priority Health Concerns of Latin American Migrants in Spain- A Participatory Qualitative Study

Background

An estimated 2.7 million Latin Americans reside in Europe, mostly in Spain. Part of a broader project aimed at developing a research agenda on the health status and determinants of this population, this qualitative study engaged Latin American migrants in the identification of research priorities.

Methods

We conducted 30 group discussions between November 2012—March 2013 with 84 participants purposively selected for maximum diversity in Madrid and Barcelona (Spain). We facilitated sequences of task-oriented visual activities to explore their views on priority health concerns. We tape-recorded and transcribed discussions and developed a coding frame based on socio-ecological frameworks, which we applied to all the data using NVIVO-10. A final round of eight group discussions allowed us to triangulate and enrich interpretations by including participants’ insights.

Findings

The cumulative toll of daily stresses was the major health concern perceived by a population that conceptualised ill-health as a constellation of symptoms rather than as specific diseases. Work-related factors, legislative frameworks regulating citizenship entitlements and feeling ethnically discriminated were major sources of psycho-social strain. Except for sexually transmitted infections, participants rarely referred to communicable diseases as a concern. The perception that clinicians systematically prescribed painkillers discouraged health seeking and fostered self-medication. Participants felt that the medicalised, chemicalised, sexually liberal and accelerated culture of the host society damaged their own, and the local populations’ health.

Conclusion

Health systems bear a disproportionate responsibility in addressing health problems rooted in other sectors. Occupational and migration policies should be recognised explicitly as health policies. The mismatch between researchers’ emphasis on communicable infections and the health concerns of Latin American migrants highlights the need for greater interaction between different forms of knowledge. In this process, the biomedical culture of reliance on pharmacological solutions should not remain unquestioned.     

Adherence to Tuberculosis Treatment among Migrant Pulmonary Tuberculosis Patients in Shandong,China: A Quantitative Survey Study

Adherence to TB treatment is the most important requirement for efficient TB control. Migrant TB patients’ “migratory” nature affects the adherence negatively, which presents an important barrier for National TB Control Program in China. Therefore, TB control among migrants is of high importance.The aim of this study is to describe adherence to TB treatment among migrant TB patients and to identify factors associated with adherence. A total of 12 counties/districts of Shandong Province, China were selected as study sites. 314 confirmed smear positive TB patients were enrolled between August 2^nd 2008 and October 17^th 2008, 16% of whom were non-adherent to TB therapy. Risk factors for non-adherence were: the divorced or bereft of spouse, patients not receiving TB-related health education before chemotherapy, weak incentives for treatment adherence, and self supervision on treatment. Based on the risk factors identified, measures are recommended such as implementing health education for all migrant patients before chemotherapy and encouraging primary care workers to supervise patients.     

Beyond UHC: Monitoring Health and Social Protection Coverage in the Context of Tuberculosis Care and Prevention

Tuberculosis (TB) remains a major global public health problem. In all societies, the disease affects the poorest individuals the worst. A new post-2015 global TB strategy has been developed by WHO, which explicitly highlights the key role of universal health coverage (UHC) and social protection. One of the proposed targets is that “No TB affected families experience catastrophic costs due to TB.” High direct and indirect costs of care hamper access, increase the risk of poor TB treatment outcomes, exacerbate poverty, and contribute to sustaining TB transmission. UHC, conventionally defined as access to health care without risk of financial hardship due to out-of-pocket health care expenditures, is essential but not sufficient for effective and equitable TB care and prevention. Social protection interventions that prevent or mitigate other financial risks associated with TB, including income losses and non-medical expenditures such as on transport and food, are also important. We propose a framework for monitoring both health and social protection coverage, and their impact on TB epidemiology. We describe key indicators and review methodological considerations. We show that while monitoring of general health care access will be important to track the health system environment within which TB services are delivered, specific indicators on TB access, quality, and financial risk protection can also serve as equity-sensitive tracers for progress towards and achievement of overall access and social protection.

This paper is part of the PLOS Universal Health Coverage Collection.

Summary Points

1. The WHO has developed a post-2015 Global TB Strategy emphasizing that significant improvement to TB care and prevention will be impossible without the progressive realization of both universal health coverage and social protection. This paper discusses indicators and measurement approaches for both.
2. While access to high-quality TB diagnosis and treatment has improved dramatically in recent decades, there is still insufficient coverage, especially for correct diagnosis and treatment of multi-drug resistant TB.
3. Continued and expanded monitoring of effective coverage of TB diagnosis and treatment is needed, for which further improvements to existing surveillance systems are required.
4. Many households face severe financial hardship due to TB. Out-of-pocket costs for medical care, transport, and food are often high. However, income loss is the largest financial threat for TB-affected households.
5. Consequently, the financial risk protection target in the post-2015 Global TB Strategy—“No TB affected families experience catastrophic costs due to TB”—concerns all direct costs as well as income loss. This definition is more inclusive than the one conventionally used for “catastrophic health expenditure,” which concerns only direct medical costs.

     

Self-Administered Tuberculosis Treatment Outcomes in a Tribal Population on the Indo-Myanmar Border,Nagaland, India

Background

Multiple strategies are being adopted by national tuberculosis (TB) programmes to achieve universal coverage of tuberculosis treatment. However, populations living in ‘hard-to-reach’ areas of north-east India have poor access to health services. Our study aimed to detail treatment outcomes in TB program supported by Médecins Sans Frontières (MSF) and using an alternative model of TB treatment delivery in Mon district, Nagaland, India.

Methods

This was a retrospective cohort study of TB patients, initiated on self-administered therapy (SAT) through Mon District Hospital, Nagaland, India between April 2012 and March 2013.

Results

A total of 238 tuberculosis patients had final TB treatment outcomes during the study period, including 82 and 156 from semi-urban and rural areas respectively. The majority of patients (62%, 147/238) were suffering from pulmonary, smear-positive tuberculosis. Overall, 74% of patients (175/238) had successful outcomes, being cured or having completed their treatment. Females (81%), pulmonary TB patients (75%) and those on a Category I regimen (79%) had better treatment success rates than males (67%), extra-pulmonary TB patients (62%) and patients on a Category II regimen (61%). The univariate and bivariate analyses found age, sex and TB treatment regimen significantly associated with unsuccessful TB treatment outcomes (defined as death, loss-to-follow-up and failure). However, only older age showed significance in a multivariate binary logistic regression model.

Conclusion

Our study suggests that self-administered TB treatment is feasible for patients living in areas with limited or no access to health services. The relatively low number of patients with adverse outcomes suggests that SAT models are safe; other advantages include the need for fewer resources and less frequent movements by patients. National TB programmes should consider allowing SAT strategies for delivery of TB treatment to ‘hard-to-reach’ populations, which could in turn help to achieve universal coverage and contribute to global TB elimination by 2050.     

Active Case Finding of Tuberculosis (TB) in an Emergency Room in a Region with High Prevalence of TB in Brazil

Setting

Public hospital emergency room (ER) in Porto Alegre, Brazil, a setting with high prevalence of tuberculosis (TB) and human immunodeficiency virus (HIV) infection.

Objective

To determine the prevalence of PTB, using a symptom based active case finding (ACF) strategy in the ER of a public hospital in an area with high prevalence of TB and HIV, as well as variables associated with pulmonary TB diagnosis.

Methods

Cross sectional study. All patients ≥18 years seeking care at the ER were screened for respiratory symptoms and those with cough ≥2 weeks were invited to provide a chest radiograph and two unsupervised samples of sputum for acid-fast bacilli smear and culture.

Results

Among 31,267 admissions, 6,273 (20.1%) reported respiratory symptoms; 197 reported cough ≥2 weeks, of which pulmonary TB was diagnosed in 30. In multivariate analysis, the variables associated with a pulmonary tuberculosis diagnosis were: age (OR 0.94, 95% CI: 0.92–0.97; p<0.0001), sputum production (OR 0.18, 95% CI 0.06–0.56; p = 0.003), and radiographic findings typical of TB (OR 12.11, 95% CI 4.45–32.93; p<0.0001).

Conclusions

This study identified a high prevalence of pulmonary TB among patients who sought care at the emergency department of a tertiary hospital, emphasizing the importance of regular screening of all comers for active TB in this setting.     

The impact of a knowledge translation intervention employing educational outreach and a point-of-care reminder tool vs standard lay health worker training on tuberculosis treatment completion rates: study protocol for a cluster randomized controlled trial

BackgroundDespite availability of effective treatment, tuberculosis (TB) remains an important cause of morbidity and mortality globally, with low- and middle-income countries most affected. In many such settings, including Malawi, the high burden of disease and severe shortage of skilled healthcare workers has led to task-shifting of outpatient TB care to lay health workers (LHWs). LHWs improve access to healthcare and some outcomes, including TB completion rates, but lack of training and supervision limit their impact. The goals of this study are to improve TB care provided by LHWs in Malawi by refining, implementing, and evaluating a knowledge translation strategy designed to address a recognized gap in LHWs’ TB and job-specific knowledge and, through this, to improve patient outcomes.Methods/designWe are employing a mixed-methods design that includes a pragmatic cluster randomized controlled trial and a process evaluation using qualitative methods. Trial participants will include all health centers providing TB care in four districts in the South East Zone of Malawi. The intervention employs educational outreach, a point-of-care reminder tool, and a peer support network. The primary outcome is proportion of treatment successes, defined as the total of TB patients cured or completing treatment, with outcomes taken from Ministry of Health treatment records. With an alpha of 0.05, power of 0.80, a baseline treatment success of 0.80, intraclass correlation coefficient of 0.1 based on our pilot study, and an estimated 100 clusters (health centers providing TB care), a minimum of 6 patients per cluster is required to detect a clinically significant 0.10 increase in the proportion of treatment successes. Our process evaluation will include interviews with LHWs and patients, and a document analysis of LHW training logs, quarterly peer trainer meetings, and mentorship meeting notes. An estimated 10–15 LHWs and 10–15 patients will be required to reach saturation in each of 2 planned interview periods, for a total of 40–60 interview participants.DiscussionThis study will directly inform the efforts of knowledge users within TB care and, through extension of the approach, other areas of care provided by LHWs in Malawi and other low- and middle-income countries.

Trial registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT02533089","term_id":"NCT02533089"}}NCT02533089. Registered 20 August 2015. Protocol Date/Version 29 May 2016/Version 2.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1563-2) contains supplementary material, which is available to authorized users.