Search

ObjectiveTo assess implementation and to identify barriers and facilitators to implementation, sustainability and scalability of an implementation strategy to provide lay health workers (LHWs) with the knowledge, skills and tools needed to implement an intervention to support patient tuberculosis (TB) treatment adherence.DesignMixed-methods design including a cluster randomised controlled trial and process evaluation informed by the RE-AIM framework.SettingForty-five health centres (HCs) in four districts in the south east zone of Malawi, who had an opportunity to receive cascade training.ParticipantsForty-five peer-trainers (PTs), 23 patients and 20 LHWs.InterventionImplementation strategy employing peer-led educational outreach, a clinical support tool and peer support network to implement a TB treatment adherence intervention.Outcome measuresProcess data were collected from study initiation to the end-of-study PT meeting, and included: LHW and patient interviews, quarterly PT meeting notes, training logs and study team observations and meeting notes. Data sources were first analysed in isolation, followed by method, data source and analyst triangulation. Analyses were conducted independently by two study team members, and themes revised through discussion and involvement of additional study team members as needed.ResultsForty-one HCs (91%) trained at least one LHW. Of 256 LHWs eligible to participate at study start 152 (59%) completed training, with the proportion trained per HC ranging from 0% to 100% at the end of initial cascade training. Lack of training incentives was the primary barrier to implementation, with intrinsic motivation to improve knowledge and skills, and to improve patient care and outcomes the primary facilitators of participation.ConclusionWe identified important challenges to and potential facilitators of implementation, scalability and sustainability, of the TB treatment adherence intervention. Findings provide guidance to scale-up, and use of the implementation strategies employed, to address LHW training and supervision in other areas.Trial registration numberNCT02533089.

Background TB remains a major global health problem. It is particularly prevalent in prisons in sub-Saharan Africa due to overcrowding, malnutrition, high HIV prevalence and insufficient medical services. Prisoners have experienced worse TB treatment outcomes than the general population. The researchers investigated the TB treatment outcomes and predictors of unsuccessful treatment outcomesamong prisoners and the general population in Zomba, Malawi. Methods We retrospectively reviewed TB registers of prisoners and the general population diagnosed with TB from January 2011 to December 2016 at Zomba Maximum Central Prison and Zomba Central Hospital, Malawi. The study used routinely collected data extracted from national, standardized TB treatment monitoring tools. Successful treatment outcome was classified as the total for cured and completed treatment while unsuccessful treatment outcome was classified as the total of deaths and treatment failures. We used descriptive statistics to compare the demographics and TB treatment parameters among prisoners and non – prisoners and computed multivariate analysis to predict the independent factors of unsuccessful treatment outcomes. Results Of 1652 registered cases, 27% were prisoners (all males) and 72% were non-prisoners (58% males). The median age was 35 years (IQR: 29–42); 76% were Pulmonary TB cases (78% among prisoners vs 75% among general population); 83% were new TB cases (77% among prisoners vs 86% among general population); and 65% were HIV positive (50% among prisoners vs 71% among general population). Regarding treatment outcome, 1472 (89%) were cured and/or completed treatment (93% among prisoners vs 88% among general population), 2(0.2%) were treatment failures, 122 (8%) died (5% among prisoners vs 8% among general population) and 55 (3%) were not evaluated (1% among prisoners vs 4% among general population). Unsuccessful TB treatment outcomes were associated with age greater than 35 years (aOR = 0.68: 95% C.I: 0.58–0.80), Extra-Pulmonary TB (aOR = 1.69: 95% C.I: 1.08–2.63) andHIV positive status (aOR = 0.63: 95% C.I: 0.42–0.94). Conclusion Maximum prisons provide a stable population that can be easily monitored throughout the course of TB treatment. Good TB treatment outcomes which are comparable to the general population can be achieved among Malawian prisoners despite the challenging prison conditions.

Background TB remains a major global health problem. it is particularly prevalent in prisons in sub-Saharan Africa. Prisoners have experienced worse TB treatment outcomes than the general population. The researchers investigated the TB treatment outcomes and pre d ictors of unsuccessful treatment outcomes among prisoners and the general population. Methods We retrospectively reviewed TB registers of prisoners and the general population diagnosed with TB from January 2011 to December 2016 at Zomba Maximum Central Prison and Zomba Central Hospital, Malawi. The study used routinely collected data extracted from national, standardized TB treatment monitoring tools. Successful treatment outcome was classified as the total for cured and completed treatment while unsuccessful treatment outcome was classified as the total of deaths and treatment failures. We used descriptive statistics to compare the demographics and TB treatment parameters among prisoners and non – prisoners and computed multivariate analysis to predict the independent factors of unsuccessful treatment outcomes. Results Of 1652 registered cases, 27% were prisoners (all males) and 72% were non-prisoners (58 % males). The median age was 35 years (IQR: 29 - 42); 76 % were Pulmonary TB cases (78 % among prisoners vs 75% among non-prisoners); 83 % were new TB cases (77% among prisoners vs 86% among non-prisoners); and 65 % were HIV positive (50 % among prisoners vs 71% among non – prisoners). Regarding treatment outcome, 1472 (89%) were cured and/or completed treatment (93% among prisoners vs 88 % among non – prisoners), 2 (0.2%) were treatment failures, 122 (8%) died (5 % among prisoners vs 8 % among non – prisoners) and 55 (3%) were not evaluated (1% among prisoners vs 4% among non – prisoners). Unsuccessful TB treatment outcomes were associated with age greater than 35 years (aOR = 0.68: 95% C.I: 0.58 – 0.80), Extra-Pulmonary TB (aOR=1.69: 95% C.I: 1.08 – 2.63) andHIV positive status (aOR = 0.63: 95 % C.I: 0.42 – 0.94). Conclusion Maximum prisons provide a stable population that can be easily monitored during TB treatment. Good TB treatment outcomes comparable to the general population can be achieved among prisoners despite the challenging prison conditions.

PURPOSE: To identify factors influencing patients anti-retroviral therapy (ART) adherence at four clinics in Botswana. DESIGN: Quantitative descriptive. Structured interviews were conducted with a random sample of 400 patients out of the population of all patients attending the four randomly selected ART clinics in Botswana during April and May 2007. METHODS: Data were analysed using SPSS version 13. Chi-square and p-value calculations were done to test significance of the relationships between categories or variables. FINDINGS: Patient-centred barriers to ART adherence included inadequate knowledge about ART human immunodeficiency virus (HIV) acquired immunodeficiency syndrome (AIDS) CD4 cell and viral-load results stigma travelling costs waiting times at clinics side effects of ART use of traditional (indigenous or folk) medicines and abuse of alcohol. Service-centred barriers included nurses attitudes and knowledge health workers inability to conduct home visits and to contact defaulters limited clinic hours delays in getting CD4 and viral-load results. CONCLUSIONS: ART adherence requires more than free ART. Adherence levels will improve if both patient-centred and service-centred barriers are addressed. CLINICAL RELEVANCE: Nurses play key roles in educating patients about ART adherence and side effects but they should also educate patients about CD4 and viral-load test results and about the dangers of using traditional medicines and alcohol with ART. Shorter waiting times at clinics could make ART patients lives more manageable.