Health system barriers to implementation of TB preventive strategies in South African primary care facilities

Eva Van Ginderdeuren, Jean Bassett, Colleen Hanrahan, Lillian Mutunga, Annelies Van Rie

Research output: Contribution to journalArticle

Abstract

Background Isoniazid preventive therapy (IPT) is a key component of TB/HIV control, but few countries achieve high IPT coverage. Methods Using a behavioural COM-B design approach, the intervention consisted of a training on IPT guidelines and tuberculin skin testing (TST), identification of the optimal IPT implementation strategy by the health care workers (HCWs) of 3 primary care clinics, and a 2-month mentoring period. Using routine register data, TST and IPT uptake was determined 3 months before and 5 months after the intervention. Records were reviewed to identify factors associated with IPT initiation and HCW fidelity to the guidelines. A survey among HCWs was conducted to determine barriers to IPT. Results Two clinics implemented TST-guided IPT for all clients receiving HIV care, one clinic decided against use of TST. According to routine register data, the proportion of clients initiating IPT increased substantially at the clinic not opting for TST (6% vs 36%), but minimally (34% vs 37% and 0.7% vs 3%) in the two other clinics. TST uptake did not increase (0 vs 0% and 0.5%). In addition to poor IPT uptake, HCW fidelity to investigation for TB and timing of IPT initiation was poor, with only 68% of symptomatic patients investigated and IPT initiation delayed to a median of 374 days post-ART initiation. In multivariate analysis, pregnancy (aOR 18.62, 95% CI 6.99–53.46), recent HIV diagnosis (aOR 3.65, 95% CI 1.73–7.41), being on ART (aOR 9.44, 95% CI 3.05–36.17), and CD4 <500 cells/mm 3 (aOR 2.19, 95% CI 1.22–4.18) were associated with IPT initiation. Time needed to perform a TST, motivating patients to return for TST reading, and low IPT patient awareness were the main barriers to IPT implementation. Conclusion Despite using a behavioural intervention framework including training and participatory development of the clinic IPT strategy, HCW fidelity to the guidelines was poor, resulting in low TST coverage and low IPT uptake under primary care conditions. To achieve the benefits of IPT, health system level approaches including TST-free guidelines and sensitization are needed.

Original languageEnglish (US)
Article numbere0212035
JournalPloS one
Volume14
Issue number2
DOIs
StatePublished - Feb 1 2019

Fingerprint

isoniazid
Isoniazid
Primary Health Care
Health
tuberculin
therapeutics
Tuberculin
skin (animal)
Skin
Testing
health care workers
Health care
Therapeutics
testing
Guidelines
Delivery of Health Care
uptake mechanisms
HIV
Health Care Surveys
mentoring

ASJC Scopus subject areas

  • Biochemistry, Genetics and Molecular Biology(all)
  • Agricultural and Biological Sciences(all)

Cite this

Health system barriers to implementation of TB preventive strategies in South African primary care facilities. / Van Ginderdeuren, Eva; Bassett, Jean; Hanrahan, Colleen; Mutunga, Lillian; Van Rie, Annelies.

In: PloS one, Vol. 14, No. 2, e0212035, 01.02.2019.

Research output: Contribution to journalArticle

Van Ginderdeuren, Eva ; Bassett, Jean ; Hanrahan, Colleen ; Mutunga, Lillian ; Van Rie, Annelies. / Health system barriers to implementation of TB preventive strategies in South African primary care facilities. In: PloS one. 2019 ; Vol. 14, No. 2.
@article{2b3ccce9cd4642c0acbd940255a93953,
title = "Health system barriers to implementation of TB preventive strategies in South African primary care facilities",
abstract = "Background Isoniazid preventive therapy (IPT) is a key component of TB/HIV control, but few countries achieve high IPT coverage. Methods Using a behavioural COM-B design approach, the intervention consisted of a training on IPT guidelines and tuberculin skin testing (TST), identification of the optimal IPT implementation strategy by the health care workers (HCWs) of 3 primary care clinics, and a 2-month mentoring period. Using routine register data, TST and IPT uptake was determined 3 months before and 5 months after the intervention. Records were reviewed to identify factors associated with IPT initiation and HCW fidelity to the guidelines. A survey among HCWs was conducted to determine barriers to IPT. Results Two clinics implemented TST-guided IPT for all clients receiving HIV care, one clinic decided against use of TST. According to routine register data, the proportion of clients initiating IPT increased substantially at the clinic not opting for TST (6{\%} vs 36{\%}), but minimally (34{\%} vs 37{\%} and 0.7{\%} vs 3{\%}) in the two other clinics. TST uptake did not increase (0 vs 0{\%} and 0.5{\%}). In addition to poor IPT uptake, HCW fidelity to investigation for TB and timing of IPT initiation was poor, with only 68{\%} of symptomatic patients investigated and IPT initiation delayed to a median of 374 days post-ART initiation. In multivariate analysis, pregnancy (aOR 18.62, 95{\%} CI 6.99–53.46), recent HIV diagnosis (aOR 3.65, 95{\%} CI 1.73–7.41), being on ART (aOR 9.44, 95{\%} CI 3.05–36.17), and CD4 <500 cells/mm 3 (aOR 2.19, 95{\%} CI 1.22–4.18) were associated with IPT initiation. Time needed to perform a TST, motivating patients to return for TST reading, and low IPT patient awareness were the main barriers to IPT implementation. Conclusion Despite using a behavioural intervention framework including training and participatory development of the clinic IPT strategy, HCW fidelity to the guidelines was poor, resulting in low TST coverage and low IPT uptake under primary care conditions. To achieve the benefits of IPT, health system level approaches including TST-free guidelines and sensitization are needed.",
author = "{Van Ginderdeuren}, Eva and Jean Bassett and Colleen Hanrahan and Lillian Mutunga and {Van Rie}, Annelies",
year = "2019",
month = "2",
day = "1",
doi = "10.1371/journal.pone.0212035",
language = "English (US)",
volume = "14",
journal = "PLoS One",
issn = "1932-6203",
publisher = "Public Library of Science",
number = "2",

}

TY - JOUR

T1 - Health system barriers to implementation of TB preventive strategies in South African primary care facilities

AU - Van Ginderdeuren, Eva

AU - Bassett, Jean

AU - Hanrahan, Colleen

AU - Mutunga, Lillian

AU - Van Rie, Annelies

PY - 2019/2/1

Y1 - 2019/2/1

N2 - Background Isoniazid preventive therapy (IPT) is a key component of TB/HIV control, but few countries achieve high IPT coverage. Methods Using a behavioural COM-B design approach, the intervention consisted of a training on IPT guidelines and tuberculin skin testing (TST), identification of the optimal IPT implementation strategy by the health care workers (HCWs) of 3 primary care clinics, and a 2-month mentoring period. Using routine register data, TST and IPT uptake was determined 3 months before and 5 months after the intervention. Records were reviewed to identify factors associated with IPT initiation and HCW fidelity to the guidelines. A survey among HCWs was conducted to determine barriers to IPT. Results Two clinics implemented TST-guided IPT for all clients receiving HIV care, one clinic decided against use of TST. According to routine register data, the proportion of clients initiating IPT increased substantially at the clinic not opting for TST (6% vs 36%), but minimally (34% vs 37% and 0.7% vs 3%) in the two other clinics. TST uptake did not increase (0 vs 0% and 0.5%). In addition to poor IPT uptake, HCW fidelity to investigation for TB and timing of IPT initiation was poor, with only 68% of symptomatic patients investigated and IPT initiation delayed to a median of 374 days post-ART initiation. In multivariate analysis, pregnancy (aOR 18.62, 95% CI 6.99–53.46), recent HIV diagnosis (aOR 3.65, 95% CI 1.73–7.41), being on ART (aOR 9.44, 95% CI 3.05–36.17), and CD4 <500 cells/mm 3 (aOR 2.19, 95% CI 1.22–4.18) were associated with IPT initiation. Time needed to perform a TST, motivating patients to return for TST reading, and low IPT patient awareness were the main barriers to IPT implementation. Conclusion Despite using a behavioural intervention framework including training and participatory development of the clinic IPT strategy, HCW fidelity to the guidelines was poor, resulting in low TST coverage and low IPT uptake under primary care conditions. To achieve the benefits of IPT, health system level approaches including TST-free guidelines and sensitization are needed.

AB - Background Isoniazid preventive therapy (IPT) is a key component of TB/HIV control, but few countries achieve high IPT coverage. Methods Using a behavioural COM-B design approach, the intervention consisted of a training on IPT guidelines and tuberculin skin testing (TST), identification of the optimal IPT implementation strategy by the health care workers (HCWs) of 3 primary care clinics, and a 2-month mentoring period. Using routine register data, TST and IPT uptake was determined 3 months before and 5 months after the intervention. Records were reviewed to identify factors associated with IPT initiation and HCW fidelity to the guidelines. A survey among HCWs was conducted to determine barriers to IPT. Results Two clinics implemented TST-guided IPT for all clients receiving HIV care, one clinic decided against use of TST. According to routine register data, the proportion of clients initiating IPT increased substantially at the clinic not opting for TST (6% vs 36%), but minimally (34% vs 37% and 0.7% vs 3%) in the two other clinics. TST uptake did not increase (0 vs 0% and 0.5%). In addition to poor IPT uptake, HCW fidelity to investigation for TB and timing of IPT initiation was poor, with only 68% of symptomatic patients investigated and IPT initiation delayed to a median of 374 days post-ART initiation. In multivariate analysis, pregnancy (aOR 18.62, 95% CI 6.99–53.46), recent HIV diagnosis (aOR 3.65, 95% CI 1.73–7.41), being on ART (aOR 9.44, 95% CI 3.05–36.17), and CD4 <500 cells/mm 3 (aOR 2.19, 95% CI 1.22–4.18) were associated with IPT initiation. Time needed to perform a TST, motivating patients to return for TST reading, and low IPT patient awareness were the main barriers to IPT implementation. Conclusion Despite using a behavioural intervention framework including training and participatory development of the clinic IPT strategy, HCW fidelity to the guidelines was poor, resulting in low TST coverage and low IPT uptake under primary care conditions. To achieve the benefits of IPT, health system level approaches including TST-free guidelines and sensitization are needed.

UR - http://www.scopus.com/inward/record.url?scp=85061492196&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85061492196&partnerID=8YFLogxK

U2 - 10.1371/journal.pone.0212035

DO - 10.1371/journal.pone.0212035

M3 - Article

C2 - 30763378

AN - SCOPUS:85061492196

VL - 14

JO - PLoS One

JF - PLoS One

SN - 1932-6203

IS - 2

M1 - e0212035

ER -