Unlocking the health system barriers to maximise the uptake and utilisation of molecular diagnostics in low-income and middle-income country setting.

BACKGROUND: Early access to diagnosis is crucial for effective management of any disease including tuberculosis (TB). We investigated the barriers and opportunities to maximise uptake and utilisation of molecular diagnostics in routine healthcare settings. METHODS: Using the implementation of WHO approved TB diagnostics, Xpert Mycobacterium tuberculosis/rifampicin (MTB/RIF) and Line Probe Assay (LPA) as a benchmark, we evaluated the barriers and how they could be unlocked to maximise uptake and utilisation of molecular diagnostics. RESULTS: Health officers representing 190 districts/counties participated in the survey across Kenya, Tanzania and Uganda. The survey findings were corroborated by 145 healthcare facility (HCF) audits and 11 policy-maker engagement workshops. Xpert MTB/RIF coverage was 66%, falling behind microscopy and clinical diagnosis by 33% and 1%, respectively. Stratified by HCF type, Xpert MTB/RIF implementation was 56%, 96% and 95% at district, regional and national referral hospital levels. LPA coverage was 4%, 3% below culture across the three countries. Out of 111 HCFs with Xpert MTB/RIF, 37 (33%) used it to full capacity, performing ≥8 tests per day of which 51% of these were level five (zonal consultant and national referral) HCFs. Likewise, 75% of LPA was available at level five HCFs. Underutilisation of Xpert MTB/RIF and LPA was mainly attributed to inadequate-utilities, 26% and human resource, 22%. Underfinancing was the main reason underlying failure to acquire molecular diagnostics. Second to underfinancing was lack of awareness with 33% healthcare administrators and 49% practitioners were unaware of LPA as TB diagnostic. Creation of a national health tax and decentralising its management was proposed by policy-makers as a booster of domestic financing needed to increase access to diagnostics. CONCLUSION: Our findings suggest higher uptake and utilisation of molecular diagnostics at tertiary level HCFs contrary to the WHO recommendation. Country-led solutions are crucial for unlocking barriers to increase access to diagnostics.

Qualitative assessment of the impact of socioeconomic and cultural barriers on uptake and utilisation of tuberculosis diagnostic and treatment tools in East Africa: a cross-sectional study.

OBJECTIVES: Early diagnosis and timely treatment are key elements of a successful healthcare system. We assessed the role of socioeconomic and cultural norms in accelerating or decelerating uptake and utilisation of health technologies into policy and practice. SETTING: Secondary and tertiary level healthcare facilities (HCFs) in three East African countries. Level of HCF was selected based on the WHO recommendation for implantation of tuberculosis (TB) molecular diagnostics. PARTICIPANTS: Using implementation of TB diagnostics as a model, we purposively selected participants (TB patients, carers, survivors, healthcare practitioners, community members, opinion leaders and policy-makers) based on their role as stakeholders. In-depth interviews, key informant interviews and focus group discussions were held to collect the data between 2016 and 2018. The data were transcribed, translated, coded and analysed by thematic-content analysis. RESULTS: A total of 712 individuals participated in the study. Socioeconomic and cultural factors such as poverty, stigma and inadequate knowledge about causes of disease and available remedies, cultural beliefs were associated with low access and utilisation of diagnostic and treatment tools for TB. Poverty made people hesitate to seek formal healthcare resulting in delayed diagnosis and resorting to self-medication and cheap herbal alternatives. Fear of stigma made people hide their sickness and avoid reporting for follow-up treatment visits. Inadequate knowledge and beliefs were fertile ground for aggravated stigma and believing that diseases like TB are caused by spirits and thus cured by spiritual rituals or religious prayers. Cultural norms were also the basis of gender-based imbalance in accessing care, 'I could not go to hospital without my husband's permission', TB survivor. CONCLUSION: Our findings show that socioeconomic and cultural factors are substantial 'roadblocks' to accelerating the uptake and utilisation of diagnostic and treatment tools. Resolving these barriers should be given equal attention as is to health system barriers.

Spatial Analysis of Ambient Air Pollution and Cardiovascular Disease (CVD) Hospitalization Across Sweden.

The associations of multiple pollutants and cardiovascular disease (CVD) morbidity, and the spatial variations of these associations have not been nationally studied in Sweden. The main aim of this study was, thus, to spatially analyze the associations between ambient air pollution (black carbon, carbon monoxide, particulate matter (both <10 µm and <2.5 µm in diameter) and Sulfur oxides considered) and CVD admissions while controlling for neighborhood deprivation across Sweden from 2005 to 2010. Annual emission estimates across Sweden along with admission records for coronary heart disease, ischemic stroke, atherosclerotic and aortic disease were obtained and aggregated at Small Areas for Market Statistics level. Global associations were analyzed using global Poisson regression and spatially autoregressive Poisson regression models. Spatial non-stationarity of the associations was analyzed using Geographically Weighted Poisson Regression. Generally, weak but significant associations were observed between most of the air pollutants and CVD admissions. These associations were non-homogeneous, with more variability in the southern parts of Sweden. Our study demonstrates significant spatially varying associations between ambient air pollution and CVD admissions across Sweden and provides an empirical basis for developing healthcare policies and intervention strategies with more emphasis on local impacts of ambient air pollution on CVD outcomes in Sweden.

Establishing spatially-enabled health registry systems using implicit spatial data pools: case study - Uganda.

BACKGROUND: Spatial epidemiological analyses primarily depend on spatially-indexed medical records. Some countries have devised ways of capturing patient-specific spatial details using ZIP codes, postcodes or personal numbers, which are geocoded. However, for most resource-constrained African countries, the absence of a means to capture patient resident location as well as inexistence of spatial data infrastructures makes capturing of patient-level spatial data unattainable. METHODS: This paper proposes and demonstrates a creative low-cost solution to address the issue. The solution is based on using interoperable web services to capture fine-scale locational information from existing "spatial data pools" and link them to the patients' information. RESULTS: Based on a case study in Uganda, the paper presents the idea and develops a prototype for a spatially-enabled health registry system that allows for fine-level spatial epidemiological analyses. CONCLUSION: It has been shown and discussed that the proposed solution is feasible for implementation and the collected spatially-indexed data can be used in spatial epidemiological analyses to identify hotspot areas with elevated disease incidence rates, link health outcomes to environmental exposures, and generally improve healthcare planning and provisioning.

Spatial analysis of HIV-TB co-clustering in Uganda.

BACKGROUND: Tuberculosis (TB) is the leading cause of death for individuals infected with Human immunodeficiency virus (HIV). Conversely, HIV is the most important risk factor in the progression of TB from the latent to the active status. In order to manage this double epidemic situation, an integrated approach that includes HIV management in TB patients was proposed by the World Health Organization and was implemented in Uganda (one of the countries endemic with both diseases). To enable targeted intervention using the integrated approach, areas with high disease prevalence rates for TB and HIV need to be identified first. However, there is no such study in Uganda, addressing the joint spatial patterns of these two diseases. METHODS: This study uses global Moran's index, spatial scan statistics and bivariate global and local Moran's indices to investigate the geographical clustering patterns of both diseases, as individuals and as combined. The data used are TB and HIV case data for 2015, 2016 and 2017 obtained from the District Health Information Software 2 system, housed and maintained by the Ministry of Health, Uganda. RESULTS: Results from this analysis show that while TB and HIV diseases are highly correlated (55-76%), they exhibit relatively different spatial clustering patterns across Uganda. The joint TB/HIV prevalence shows consistent hotspot clusters around districts surrounding Lake Victoria as well as northern Uganda. These two clusters could be linked to the presence of high HIV prevalence among the fishing communities of Lake Victoria and the presence of refugees and internally displaced people camps, respectively. The consistent cold spot observed in eastern Uganda and around Kasese could be explained by low HIV prevalence in communities with circumcision tradition. CONCLUSIONS: This study makes a significant contribution to TB/HIV public health bodies around Uganda by identifying areas with high joint disease burden, in the light of TB/HIV co-infection. It, thus, provides a valuable starting point for an informed and targeted intervention, as a positive step towards a TB and HIV-AIDS free community.