Timely treatment initiation of free drug-resistant tuberculosis care in Nigeria? : a mixed methods study of patient experience, socio-demographic characteristics and health system factors

Introduction: Au Nigeria, la couverture de la détection et du traitement de la tuberculose pharmaco-résistante (TPR) est toujours faible malgré la mise en place de services gratuits depuis 2011. Le pays se classe au sixième rang mondial avec une proportion de cas de patients résistants aux médicaments de 4,3% et de 15% dans les cas d’une réinitialisation au traitement. Le pays a aussi un fardeau élevé pour la tuberculose, la TPR, et le VIH, avec une prévalence de 219 et 11 pour 100 000 habitants pour la tuberculose et la TPR et de 1,28 pour 1 000 habitants pour le VIH. Sans traitement, la mortalité due à la tuberculose est d'environ 70% en dix ans, augmentant avec la coïnfection par le VIH, et la résistance aux médicaments; et descendant en dessous de 5% avec traitement. Les taux de survie de la tuberculose pharmaco-résistante sont plus faibles et le traitement est plus long, plus coûteux et plus toxique. Cela peut poser des défis différents à la fois pour les patients et les systèmes de santé comparativement à la tuberculose de la forme commune. Cependant, la réponse au traitement et la survie sont influencées par la détection précoce et à l'initiation rapide au traitement, idéalement dans les quatre semaines suivant le diagnostic, en particulier avec la coïnfection par le VIH. Les caractéristiques sociodémographiques interagissent souvent de manière complexe avec des facteurs systémiques, pour accroître la vulnérabilité et les désavantages - ces interactions sont particulièrement bien examinées à travers un cadre conceptuel d'équité à l'accès à la santé, et pourrait offrir des analyses et des recommandations pertinentes pour les politiques. Cette thèse explore les barrières et les facilitateurs à l’accès au diagnostic et au traitement au niveau des patients et du système de santé au Nigéria. Méthodes: Cette thèse est une étude transformative de méthodes mixtes. Nous avons d’abord réalisé une revue systématique mixte pour identifier les obstacles et les facilitateurs influençant l’accès au diagnostic et au traitement de la TPR en Afrique subsaharienne. Nous avons par la suite mené une méta-synthèse qualitative pour examiner en profondeur les obstacles aux soins de la tuberculose auxquels se heurtent les patients, la communauté, et le système de santé. Nous avons utilisé les résultats des deux revues systématiques pour affiner notre cadre conceptuel afin d'orienter la conception et l'analyse de l'étude empirique qui a suivi. Le cadre conceptuel adapté est basé sur le cadre de Levesque. Ce cadre centré sur les patients conceptualise l’accès aux soins selon des dimensions du système de santé et des patients. Cette étude comprenait également une analyse rétrospective d’une cohorte de patients diagnostiqués en 2015 (n = 996) à l'aide de données secondaires nationales et une analyse en cascade des soins de la tuberculose pharmaco-résistante entre 2013 et 2017. Nous avons mené des analyses statistiques descriptives et analytiques. Nous avons effectué une régression logistique et d'autres tests d’association pour mesurer la relation entre les variables catégorielles. L’étude qualitative était une étude de cas qui consistait à examiner la dynamique de soins du point de vue des patients (n = 86 participants, n = 7 groupes de discussions, 5 entretiens approfondis avec des patients diagnostiqués et non traités), leurs familles (n = 19 participants, n = 1 groupe de discussion, 7entretiens approfondis ), membres de la communauté (n = 23 , n=2 groupes de discussion), agents de santé (n = 5 entretiens approfondis) et gestionnaires de programme (n = 29 entretiens approfondis) dans quatre États du Nigéria. Nous avons analysé nos données qualitatives à l'aide d'une analyse thématique. Résultats: Notre revue systématique mixte et notre méta-synthèse qualitative ont indiqué des obstacles et des facilitateurs à l’accès aux soins de la tuberculose pharmaco-résistante au niveau du système de santé et des patients. Les problèmes de fonctionnement des laboratoires et des cliniques, l’absence de connaissances et les attitudes des prestataires de soins, et la gestion de l'information étaient des obstacles à l’accès aux soins de la TPR. Les facteurs facilitateurs comprenaient des outils de diagnostic plus récents, la décentralisation des services et le coût gratuit des soins. Au niveau des patients, la perte de suivi avant ou pendant les soins en raison de la perception négative des soins dans les services publics, le genre, la famille, l’engagement professionnel ou scolaire, et le recours aux soins dans le secteur privé constituaient des obstacles. Les facilitateurs étaient la séropositivité pour VIH, la multitude de symptômes, et le soutien financier des patients. Nos résultats quantitatifs ont révélé une certaine amélioration mais des progrès insuffisants dans le diagnostic et la couverture du traitement au Nigeria entre 2013 et 2017. Notre analyse en cascade a montré des abandons significatifs entre chaque étape des soins, en commençant par les tests et en terminant par l'achèvement du traitement. En moyenne, 80% des cas estimés n'ont pas eu accès au test; 75% de ceux qui ont été testé n'ont pas été diagnostiqués; 36% des personnes diagnostiquées n'ont pas commencé le traitement et 23% d'entre elles n'ont pas terminé le traitement pour la période entre 2013-2017. En 2015, les patients et les enfants atteints de la TB qui résident au nord du Nigéria avaient une probabilité de 0,3 [IC à 95% 0,1-0,7] et 0,4[0,3-0,5] de terminer le traitement une fois la maladie diagnostiquée comparativement aux patients et aux enfants qui résident au sud du pays. Les hommes avaient une probabilité de 1,34 [IC à 95% 1,0-1,7] plus élevée de terminer le traitement après le diagnostic comparativement aux femmes. La localisation géographique et les niveaux de soins étaient associés à un traitement et / ou à un traitement rapide. Notre étude qualitative a identifié des obstacles aux soins aux niveaux individuel, familial, communautaire, et du système de santé. Certains groupes sociodémographiques de patients avaient un accès inéquitable aux soins de la TPR. Alors que les patients étaient pour la plupart traités de manière égale au niveau de l'établissement, certains patients avaient plus de difficulté à accéder aux soins en fonction de leur sexe, de leur âge, de leur profession, de leur niveau d'éducation, et de leur religion. La dynamique familiale et conjugale influencent l’accès aux soins des patients, en particulier des enfants et des femmes. Elle agissait parfois comme un obstacle aux soins. D’autres facteurs qui ont probablement entravé l’accès incluaient l’absence de considérations sur les droits d’accès et la protection des patients dans les directives de traitement et les protocoles de soins. Les patients ignoraient pour la plupart les causes de la tuberculose pharmaco-résistante et la disponibilité des soins gratuits. Le nombre d'agents de santé et les problèmes de formation, la faible performance des laboratoires et des cliniques sont des obstacles aux soins de la tuberculose au niveau du système de santé. Les principaux facilitateurs à l’accès aux soins comprenaient le soutien familial, le soutien financier aux patients et le traitement gratuit. Conclusions: Malgré la gratuité des tests et des traitements de la TB pharmaco-résistante au Nigéria depuis 2011, les couvertures de diagnostic et de traitement restent constamment faibles. Les obstacles à l’accès au diagnostic et au traitement de la TB et de la TB pharmaco-résistante sont similaires. Toutefois, la TB pharmaco-résistante présente des défis particuliers en raison de la complexité des procédures de prétraitement et des toxicités résultant des médicaments eux-mêmes. Notre étude avait pour objectif de mieux comprendre les facteurs qui influencent l’accès à l'initiation au traitement de la TB pharmaco-résistante. Nos résultats montrent que les obstacles les plus importants sont l'accès aux tests et au diagnostic, malgré les progrès technologiques de diagnostic et des protocoles cliniques. Notre étude a identifié plusieurs obstacles liés aux patients et au système de santé. La plupart des patients atteints de TB pharmaco-résistante n'ont pas accès aux tests et ne sont pas diagnostiqués, souvent en raison d'un manque d'information. Les politiques et les programmes de lutte contre la tuberculose pharmaco-résistante ne sont pas toujours équitables, en particulier pour les populations vivant dans les zones rurales, les enfants, et les femmes. Les résultats de notre étude ont généré des données probantes pertinentes pour les décideurs et les partenaires internationaux pour remédier aux disparités systémiques et fournir des services plus équitables. L'élimination des obstacles à l’accès aux soins en temps opportun devrait être une priorité urgente pour améliorer le programme de lutte contre la tuberculose au Nigéria. Dans la faible détection des cas et la couverture thérapeutique, les interventions devraient viser l'équité en facilitant l’accès aux soins des populations vulnérables.Background: Detection and treatment coverage for drug-resistant tuberculosis (DR-TB) in Nigeria are persistently low despite the implementation of free diagnostic and treatment services since 2011. Nigeria has a high burden for tuberculosis, ranking 6th globally with 4.3% drug resistance in new, and 15% in retreatment cases. The World Health Organization classifies the country as a high burden for TB, DR-TB, and HIV, with a prevalence of 219 and 11 per 100,000 population for TB and DR-TB, and 1.28 per 1,000 population HIV. Without treatment, mortality from tuberculosis is approximately 70% within ten years, increasing with HIV co-infection and drug resistance - and decreasing to below 5% with treatment. DR-TB survival rates are lower, and treatment is longer, costlier, and more toxic; this may pose different challenges to both patients and health systems than is the case for drug-sensitive (DS-) TB. However, treatment response and survival are positively impacted by early detection and treatment initiation, ideally within four weeks of diagnosis, especially with HIV co-infection. Socio-demographic characteristics often interact in complex ways with systemic factors, to increase vulnerability and disadvantage – these interactions are particularly well examined through an equity of health access framework and could offer policy-relevant analyses and recommendations. This study explores patient and health system barriers and facilitators to diagnosis and treatment for DR-TB in Nigeria. Methods: This is a sequential transformative mixed-methods study. First, a mixed-methods systematic review identified barriers and facilitators affecting diagnosis and treatment for DR-TB in sub-Saharan Africa. A subsequent qualitative meta-synthesis was used to examine in more depth the patient, community, and health system barriers to TB care. The results of the systematic reviews were used to refine our conceptual framework and to guide the design and the analysis of the subsequent empirical study. The adapted conceptual framework is based on the Levesque framework for patient-centred healthcare access, which conceptualises access to care as having health system and patient dimensions. This study also included a retrospective cohort analysis of patients diagnosed in 2015 (n= 996 ) using National secondary data, and a DR-TB care cascade analysis of the period between 2013 and 2017. We used descriptive statistics, logistic regression and other tests of association to measure the relationship between variables categorical. The qualitative phase used a case study design to examine the dynamics of care from patients' perspectives (n= 86 participants, N= 7 focus group discussions (FGD), 5 in-depth interviews (IDIs) with diagnosed and untreated patients), their relatives (n= 19 participants, N= 1 FGD, 7 IDIs ), community members (n=23 in 2 FGDs), healthcare workers (n= 5 IDIs ), and program managers (n= 29 IDIs) in four States in Nigeria. We analysed our qualitative data using thematic analysis. Results: Our mixed methods systematic review and qualitative meta-synthesis revealed barriers and facilitators to DR-TB care at the health system and patient levels. Health system laboratory and clinic operational issues, poor provider knowledge and attitudes and information management were some barriers. Facilitators included newer diagnostic tools, decentralisation of services and free cost of care. At the patient level, loss to follow-up before or during care due to negative public sector care perceptions, gender, family, work or school commitments and using private sector care were some barriers. Facilitators were HIV positivity, having more symptoms, and financial support. Our quantitative findings revealed some improvement but inadequate progress in diagnosis and treatment coverage in Nigeria between 2013 and 2017. Our cascade analysis showed significant dropouts between each stage of care, starting with testing and ending with treatment completion. On average, between 2013-2017, 80% of estimated cases did not access testing; 75% of those who test were not diagnosed; 36% of those diagnosed were not initiated on treatment and 23% of these did not finish treatment. In 2015, children and patients in Northern Nigeria had odds of 0.3 [95% CI 0.1-0.7] and 0.4 [0.3-0.5] of completing treatment once diagnosed; compared with adults and patients in Southern Nigeria; while males were shown to have a 1.34 [95% CI 1.0-1.7] times greater chance of completing treatment after diagnosis compared to females.. Geographic locations and levels of care were associated with ever receiving treatment and or timely treatment. Our qualitative data and document review identified barriers to care at individual, family, community, and health systems levels. Some patient socio-demographic groups had inequitable access. While patients were mostly treated equally at the facility level, some patients experienced more difficulty accessing care based on their gender, age, occupation, educational level and religion. Parental and spousal influences affected patients, particularly children, and women, and were sometimes barriers to care. Other factors that likely hampered access include the absence of considerations for patients’ access rights and protection in the treatment guidelines and workers manuals. Patients were mostly unaware of the causes of DR-TB disease and the availability of free care. Health worker numbers and training, clinic, and operational laboratory issues limited patients’ access at the health system level. The main facilitators to care included family support, patient financial support, and free treatment. Conclusions: Despite the provision of free DR-TB testing and treatment in Nigeria since 2011, coverage for diagnosis and treatment remain persistently low. Our literature review identified many of the same access factors affecting both DS-TB and DR-TB. However, DR-TB had peculiar challenges due to complexities in pre- treatment procedures, and in toxicities as a result of the medications themselves. This study was designed to investigate the access factors impacting DR-TB treatment initiation identified in literature. However, our findings showed that the biggest barriers to DR-TB care were essentially in access to testing and diagnosis, making any advances in diagnostic technology and treatment regimens of little benefit to DR-TB patients in Nigeria. Several patient and health system factors were shown to impede access to DR-TB care, particularly for certain groups of patients. Most DR-TB patients are not accessing testing and do not get diagnosed, often due to a lack of information. Also, DR-TB policies, structures and processes are not always equitable, especially for rural dwellers, children and women. Findings from our mixed methods study provided the additional insights needed by policymakers and implementing partners to address systemic disparities and provide more equitable services based on the population's needs. Eliminating barriers that negatively impact timely access to care should be an urgent priority for the TB program in Nigeria. In Nigeria's low case-finding and treatment coverage, interventions should target equity and ease of access, specifically for the barriers identified at the patient and health system levels

Factors influencing diagnosis and treatment initiation for multidrug-resistant/rifampicin-resistant tuberculosis in six sub-Saharan African countries: A mixed-methods systematic review

Drug-resistant tuberculosis burdens fragile health systems in sub-Saharan Africa (SSA), complicated by high prevalence of HIV. Several African countries reported large gaps between estimated incidence and diagnosed or treated cases. Our review aimed to identify barriers and facilitators influencing diagnosis and treatment for drug-resistant tuberculosis (DR-TB) in SSA, which is necessary to develop effective strategies to find the missing incident cases and improve quality of care. Methods Using an integrative design, we reviewed and narratively synthesised qualitative, quantitative and mixed-methods studies from nine electronic databases: Medline, Global Health, CINAHL, EMBASE, Scopus, Web of Science, International Journal of Tuberculosis and Lung Disease, PubMed and Google Scholar (January 2006 to June 2019). Results Of 3181 original studies identified, 55 full texts were screened, and 29 retained. The studies included were from 6 countries, mostly South Africa. Barriers and facilitators to DR-TB care were identified at the health system and patient levels. Predominant health system barriers were laboratory operational issues, provider knowledge and attitudes and information management

Ease and equity of access to free DR-TB services in Nigeria- a qualitative analysis of policies, structures and processes

Introduction: Persistent low rates of case notification and treatment coverage reflect that accessing diagnosis and treatment for drug-resistant tuberculosis (DR-TB) in Nigeria remains a challenge, even though it is provided free of charge to patients. Equity in health access requires availability of comparable, appropriate services to all, based on needs, and irrespective of socio-demographic characteristics. Our study aimed to identify the reasons for Nigeria’s low rates of case-finding and treatment for DR-TB. To achieve this, we analyzed elements that facilitate or hinder equitable access for different groups of patients within the current health system to support DR-TB management in Nigeria. Methods: We conducted documentary review of guidelines and workers manuals, as well as 57 qualitative interviews, including 10 focus group discussions, with a total of 127 participants, in Nigeria. Between August and November 2017, we interviewed patients who were on treatment, their treatment supporter, and providers in Ogun and Plateau States, as well as program managers in Benue and Abuja. We adapted and used Levesque’s patient-centered access to care framework to analyze DR-TB policy documents and interview data. Results: Thematic analysis revealed inequitable access to DR-TB care for some patient socio-demographic groups. While patients were mostly treated equally at the facility level, some patients experienced more difficulty accessing care based on their gender, age, occupation, educational level and religion. Health system factors including positive provider attitudes and financial support provided to the patients facilitated equity and ease of access. However, limited coverage and the absence of patients’ access rights protection and considerations in the treatment guidelines and workers manuals likely hampered access. Conclusion: In the context of Nigeria’s low case-finding and treatment coverage, applying an equity of access framework was necessary to highlight gaps in care. Differing social contexts of patients adversely affected their access to DR-TB care. We identified several strengths in DR-TB care delivery, including the current financial support that should be sustained. Our findings highlight the need for government’s commitment and continued interventions

Pro-equity legislation, health policy and utilisation of sexual and reproductive health services by vulnerable populations in sub-Saharan Africa : a systematic review

The study reviews original primary research that examined relationships between equity-focused legislation and policy, and the utilisation of sexual and reproductive health (SRH) services by vulnerable populations in sub-Saharan Africa. Findings show that health-related legislation and policy promoted an increase in service utilisation, over time, especially for antenatal care, skilled birth attendance and facility-based delivery. However, social health inequalities persist among subgroups of women. Neither the reviewed studies or policies specifically addressed youth, people living with HIV and people with disabilities. Compared to other regions worldwide, sub-Saharan Africa had the highest average maternal mortality ratio (2017) and HIV prevalence (2018).Fonds de Recherche du Québec - Sant

Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method study

Background: Despite the availability of free drug-resistant tuberculosis (DR-TB) care in Nigeria since 2011, the country continues to tackle low case notification and treatment rates. In 2018, 11% of an estimated 21,000 cases were diagnosed and 9% placed on treatment. These low rates are nevertheless a marked improvement from 2015 when only 3.4% were diagnosed and 2.3% placed on treatment of an estimated 29,000 cases. This study describes the Nigerian DR-TB care cascade from 2013 to 2017 and considers factors influencing gaps in care. Methods: Our study utilized a mixed-method design. For the quantitative component, we utilized the national diagnosis and treatment databases, as well as the World Health Organization's estimates for prevalence to construct a 5-year care cascade: numbers of patients at each level of DR-TB care, including incident cases, individuals who accessed testing, were diagnosed, initiated treated and completed treatment in Nigeria between 2013 and 2017. Using retrospective data for patients diagnosed in 2015, we performed the Fisher's exact test to determine the association between patient (age and gender) and provider/patient (region- north or south) variables, permitting a closer look at the gaps in care revealed across the 5 years. Barriers to care were explored using framework thematic analysis of 57 qualitative interviews and focus group discussions with patients, including 5 cases not initiated on treatment from the 2015 cohort, treatment supporters, community members, healthcare workers and program managers in 2017. Results: A 5-year analysis of cascade of care data shows significant, but inadequate, increases in overall numbers of cases accessing care. On average, between 2013 and 2017, 80% of estimated cases did not access testing; 75% of those who tested were not diagnosed; 36% of those diagnosed were not initiated on treatment and 23% of these did not finish treatment. In 2015, children and patients in Northern Nigeria had odds of 0.3 [95% CI 0.1–0.7] and 0.4 [0.3–0.5] of completing treatment once diagnosed; while males were shown to have a 1.34 [95% CI 1.0–1.7] times greater chance of completing treatment after diagnosis

Rates and timeliness of treatment initiation among drug-resistant tuberculosis patients in Nigeria- A retrospective cohort study.

BackgroundThere were an estimated 580,000 new cases of multidrug/rifampicin resistant TB (DR-TB) in 2015, and only 20% were initiated on treatment. This study explored health system and patient factors associated with initiation and timeliness of treatment among DR-TB patients in Nigeria, ranked 4th globally for estimated TB cases in 2015.MethodsA retrospective cohort study using 2015 diagnosis and treatment data from the Nigerian TB program electronic records examined "treatment ever received" (yes/no) and "treatment within 30 days" (yes/no). We compared health system and patient characteristics using binomial logistic regression, while controlling for confounders.ResultsOf 996 patients diagnosed nationwide in 2015 (aged 0-87 years, median 34), 47.8% were never treated. Of those treated (n = 520), 51.2% were treated within the 30 days prescribed in the National treatment guideline. Healthcare facility locations were significantly associated with ever receiving treatment and timely treatment. Predictors of timely treatment at the national level also included level of care and patient treatment history. The South-West zone, where DR-TB programs started, showed overall better access to DR-TB healthcare.ConclusionsHealthcare facility geographic locations were significantly associated with treatment initiation and timeliness. Significant regional differences in access to DR-TB care in Nigeria persist, reflecting uneven contexts for national DR-TB treatment rollout

Partnering with the private laboratories to strengthen TB diagnostics in Nigeria

Despite being curable and preventable, tuberculosis (TB) affected 10 million people worldwide in 2020. In the seven highest TB burden countries, private providers account for more than two-thirds of initial care seeking. Closing gaps and finding the “missing people” with TB requires engagement of the private sector for better diagnostics and treatment.This review explores the efforts of a public–private partnership to enhance TB diagnostics in Nigeria, covering logistics and the distribution of GeneXpert machines and other diagnostic tools. Over three years, the Nigerian “hub and spoke” model led to a 28-fold increase in referrals of people with presumed TB in private diagnostic facilities. Various stakeholders' perspectives are also included, providing insight into opportunities and challenges of working with the private sector in this effort.As countries tackle the setbacks brought by COVID-19 and move towards reaching the End TB targets, partnerships such as these can strengthen the foundations of health systems

Tuberculosis service disruptions and adaptations during the first year of the COVID-19 pandemic in the private health sector of two urban settings in Nigeria-A mixed methods study.

Nigeria has the second largest share of undiagnosed TB cases in the world and a large private health sector estimated to be the point of initial care-seeking for 67% of TB patients. There is evidence that COVID-19 restrictions disrupted private healthcare provision, but insufficient data on how private healthcare provision changed as a result of the pandemic. We conducted qualitative interviews and a survey to assess the impact of the pandemic, and government response on private healthcare provision, and the disruptions providers experienced, particularly for TB services. Using mixed methods, we targeted policymakers, and a network of clinical facilities, laboratories, community pharmacies, and medicine vendors in Kano and Lagos, Nigeria. We interviewed 11 policymakers, surveyed participants in 2,412 private facilities. Most (n = 1,676, 70%) facilities remained open during the initial lockdown period, and most (n = 1,667, 69%) offered TB screening. TB notifications dipped during the lockdown periods but quickly recovered. Clinical facilities reported disruptions in availability of medical supplies, staff, required renovations, patient volume and income. Few private providers (n = 119, 11% in Kano; n = 323, 25% in Lagos) offered any COVID-19 screening up to the time of the survey, as these were only available in designated facilities. These findings aligned with the interviews as policymakers reported a gradual return to pre-COVID services after initial disruptions and diversion of resources to the pandemic response. Our results show that COVID-19 and control measures had a temporary impact on private sector TB care. Although some facilities saw decreases in TB notifications, private facilities continued to provide care for individuals with TB who otherwise might have been unable to seek care in the public sector. Our findings highlight resilience in the private sector as they recovered fairly quickly from pandemic-related disruptions, and the important role private providers can play in supporting TB control efforts