Provision of HIV testing services and its impact on the HIV positivity rate in the public health sector in KwaZulu-Natal: a ten-year review.

South Africa has been rated as having the most severe HIV epidemic in the world since it has one of the largest populations of people living with HIV (PLHIV). KwaZulu-Natal (KZN) is the epicentre of the HIV epidemic. The HIV test and treat services in the public health sector are critical to managing the epidemic and responding to the increase in HIV infections. The KwaZulu-Natal Department of Health (DOH) commissioned a review of the provision of HIV testing services in the province and aimed to investigate its impact on the HIV positivity rate over a ten-year period. The study was an ecological study design using data extracted from the Department's District Health Information System (DHIS). Descriptive analysis was conducted in addition to ANOVA and multiple regression analysis. The results of this study have shown that the total number of HIV tests conducted over the ten-year period in the province has increased with the highest number of HIV tests being conducted in the 2018/2019 MTEF year. ANOVA analysis indicates that there was a statistically significant difference in the total number of HIV tests conducted and the number of HIV tests per 100 000 population across the province's 11 districts (p < 0.001). Statistically significant differences were observed in the HIV testing rate and in the HIV positivity rate over the period (p < 0.001). Results from multiple regression analysis showed that the HIV testing rate per 100 000 population was the strongest predictor of the HIV positivity rate. HIV positivity among clients correlated negatively with the number of HIV tests conducted per 100 000 population (r = -0.823; p < 0.001) and the HIV testing rate (r = -0.324; p < 0.01). This study has found that HIV testing could have an impact on reducing the positivity rate of HIV in the province and is therefore an effective strategy in curbing the HIV epidemic. The KwaZulu-Natal Department of Health should ensure that strategies for implementing and maintaining HIV testing and treating services should continue at an accelerated rate in order to achieve the first 95 of the UNAIDS 2025 SDG target.

Operational manager's knowledge and attitudes toward data and universal health coverage indicators in primary health clinics in Ugu, South Africa.

Universal health coverage (UHC) aims to ensure people have access to the health services they need. Sixteen tracer indicators were developed for implementation by countries to measure UHC in the health system. South Africa uses 15 of the proposed 16 indicators. Operational managers in the public health care sector collect data and report on these indicators at a primary health clinic level. This qualitative study explored the knowledge and attitudes of managers toward data and UHC service indicators in a sub-district in Ugu, KwaZulu-Natal, South Africa. Operational managers saw data collection as information gathering, measuring performance and driving action. They understood UHC indicators as 'health for all' linking them to National Department of Health Strategic plans and saw the value of indicators for health promotion. They found the lack of training, inadequate numeracy skills, requests for data from multiple spheres of government and the indicator targets that they had to reach as challenging and untenable. While operational managers made the link between data, measuring performance and action, the limited training, skills gaps and pressures from higher levels of government may impede their ability to use data for local level planning and decision making.

Tracking the Trauma Epidemic in KwaZulu-Natal, South Africa.

BACKGROUND: Trauma remains an important cause of morbidity and mortality in South Africa, but attempts to track the epidemic are often based on mortality data, or derived from individual health facilities. This project is based on the routine collection of trauma data from all public health facilities in the province of KwaZulu-Natal (KZN), between 2012 and 2022. METHODS: Hospital level data on trauma over the past ten years was drawn from the district health information system (DHIS). Data relating to assaults, gunshots and motor vehicle collisions (MVCs) were recorded in the emergency rooms, whilst data on admissions are recorded in the wards and intensive care units. RESULTS: There were 1,263,847 emergency room visits for assaults, gunshots and MVCs over the ten-year period and trauma admissions ranged between four and five percent of the total number of hospital admissions annually. There was a dramatic decrease in trauma presentations and admissions over 2020/2021 as a result of the COVID lockdowns. Over the entire period, intentional injury was roughly twice as frequent as non-intentional injury. Intentional trauma had an almost equal ratio of blunt assault to penetrating assault. Gunshot-related assault increased dramatically over the 2021/2022 collecting period. CONCLUSIONS: The burden of trauma in KZN remains high. The unique feature of this burden is the excessively high rate of intentional trauma in the form of both blunt and penetrating mechanisms. Developing injury-prevention strategies to reduce the burden of interpersonal violence is more difficult than for unintentional trauma.

Exploring how outreach team leaders perceive community health workers' experiences of providing HIV services in KwaZulu-Natal, South Africa.

Objectives: In 2018, the KwaZulu-Natal Department of Health launched the ward-based primary health care outreach teams policy framework which sought to expand the community health worker (CHW) programme's provision of longitudinal patient support, including human immunodeficiency virus (HIV) services in communities. This study sought to explore the perceptions of outreach team leaders who supervise CHWs on their experiences of providing HIV services in the province.Study design: This was a qualitative, phenomenology study.Methods: Convenience sampling was done to select one outreach team leader from each of the 11 KwaZulu-Natal health districts to be interviewed using an interview guide. Thematic analysis, guided by the Ritchie and Spencer framework analysis, was used to analyse the data.Results: The challenges faced by CHWs in delivering HIV services were: the absence of individuals when CHWs visited their homes, self-HIV stigma, rejection of CHWs' HIV services due to traditional beliefs, CHW shortages, lack of other resources, low levels of CWH education and a lack of training. On the other hand, the provision of HIV services was fascilitated by: supportive supervision, training, having cell phones and having a positive attitude towards providing HIV services by CHWs that were HIV-positive.Conclusion: The CHWs in KwaZulu-Natal face more challenges than enablers in the provision of HIV services. The delegation of HIV services to CHWs should be aligned with their holistic empowerment by eliminating barriers to the provision of HIV services.

Facility Managers' Perceptions of Support and Supervision of Ward Based Primary Health Care Outreach Teams in National Health Insurance Pilot Districts in KwaZulu-Natal, South Africa. A Qualitative Study.

INTRODUCTION: Evidence from many countries suggests that provision of home and community-based health services, linked to care at fixed primary health care facilities, is critical to good health outcomes. In South Africa, the Ward-Based Primary Health Care Outreach Teams are well placed to provide these services. The teams report to a primary health care facility through their outreach team leader. The facility manager/operational manager provides guidance and support to the outreach team leader. AIM: The aim of the study was to explore and describe the perceptions of facility managers regarding support and supervision of ward-based outreach teams in the National Health Insurance pilot sites in Kwa Zulu-Natal. SETTING: The study was carried out in three National Health Insurance pilot districts in KwaZulu- Natal. METHODS: An exploratory qualitative design was used to interview 12 primary health care facility managers at a sub-district (municipal) level. The researchers conducted thematic analysis of data. FINDINGS: Some gaps in the supervisory and managerial relationships between ward based primary health care outreach teams and primary health care facility managers were identified. High workload at clinics may undermine the capacity of PHC facility managers to support and supervise the teams. Field supervision seems to take place only rarely and for those teams living far away from the clinic, communication with the clinic manager may be difficult. The study further highlights issues around the training and preparation of the teams. CONCLUSIONS: Ward based primary health care outreach teams have a positive impact in preventive and promotive health in rural communities. Furthermore, these teams have also made impact in improving facility indicators. However, their work does not happen without challenges.

Barriers and facilitators of rendering HIV services by community health workers in sub-Saharan Africa: a meta-synthesis.

OBJECTIVES: To synthesise qualitative studies that address the barriers to and facilitators of providing HIV services by community health workers (CHWs) in sub-Saharan Africa (SSA). DESIGN: This meta-synthesis was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We included studies that were published between 2009 and 2019. The Ritchie and Spencer framework and the Supporting the Use of Research Evidence framework were used for thematic analysis and framework analysis, respectively. The Qualitative Assessment and Review Instrument was used to assess the quality of selected studies. ELIGIBILITY CRITERIA: Qualitative studies published between 2009 and 2019, that included CHWs linked directly or indirectly to the Ministry of Health and providing HIV services in the communities. INFORMATION SOURCES: An extensive search was conducted on the following databases: EBSCOhost- (ERIC; Health Source-Nursing/Academic Edition; MEDLINE Full Text), Google Scholar and PubMed. RESULTS: Barriers to rendering of HIV services by CHWs were community HIV stigma; lack of CHW respect, CHWs' poor education and training; poor stakeholders' involvement; poor access to the communities; shortage of CHWs; unsatisfactory incentives; lack of CHW support and supervision, lack of equipment and supplies and social barriers due to culture, language and political structures. The altruistic behaviour of CHWs and the availability of job facilitated the provision of HIV services. CONCLUSION: The delivery of HIV services by CHWs in SSA is faced by more lingering barriers than facilitators. Planners and policymakers can minimise the barriers by investing in both CHW and community training regarding HIV services. Furthermore, sufficient funding should be allocated to the programme to ensure its efficiency. PROSPERO REGISTRATION NUMBER: CRD42020160012.

The Burden of Emergency Abdominal Surgery Heavily Outweighs Elective Procedures in KwaZulu-Natal Province, South Africa.

BACKGROUND: South Africa is a middle-income country with major discrepancies in wealth and access to care. There is a significant burden of surgical disease and limited access to quality health care for a large proportion of the population. This article quantifies the burden of abdominal surgery over a 6-month period in KwaZulu-Natal (KZN) province and quantifies the emergency to elective (Ee) ratio for these operations. METHODS: This study describes the abdominal operations conducted at all regional and tertiary hospitals in the public health sector of KZN province for the period of 1 July to December 31, 2015. Operations performed were tabulated in a spreadsheet and categorized as elective, emergency, and trauma. They were further subdivided by anatomical region and by specific predetermined procedures. Uncertain criteria were clarified using a modified Delphi discussion. The Ee ratio was determined using the recently described technique. RESULTS: Between June, 1st and December 31, 2015, of 13,282 operations, there were 4580 (34.5%) elective operations, 7777 (58.6%) emergency operations, and 925 (6.9%) trauma-related operations. A total of 5630 abdominal operations were performed of which 2949 were emergency procedures. There were 660 trauma-related abdominal procedures and 2021 elective procedures. There was a heavy weighting toward emergency surgeries with an Ee ratio of 145 for abdominal surgery. The previous sub-Saharan African ratio was estimated to be 62.6. CONCLUSIONS: An overview of abdominal surgery in KZN reveals a high ratio of emergency to elective surgery. This suggests that the current primary health care program is failing to detect and treat acute surgical disease timeously.

Barriers and facilitators of rendering HIV services by community health workers in sub-Saharan Africa: a meta-synthesis protocol.

INTRODUCTION: In sub-Saharan Africa (SSA), Human Immunodeficiency Virus (HIV) is the leading cause of morbidity and mortality. Community healthcare workers (CHWs) worldwide have been reported to be effective in strengthening the HIV programme by providing services such as adherence support, HIV education and safe sex education as part of their roles. The main aim of this meta-synthesis is to synthesise qualitative evidence on studies that have been conducted in SSA countries to understand the barriers to and facilitators of providing HIV services by CHWs across all settings METHODS AND ANALYSIS: This meta-synthesis will be guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses. An initial search was conducted on 15 November 2019 for studies published between 2009 and 2019 using the population exposure outcome nomenclature. We searched the EBSCOHost- (ERIC; Health Source-Nursing/Academic Edition), Google Scholar and PubMed databases for the relevant studies. The Ritchie and Spencer framework will be used for data synthesis and the Supporting the Use of Research Evidence Framework analysis will be used to analyse data. We will conduct critical appraisal on selected studies using the Qualitative Assessment and Review Instrument to limit risk of bias. ETHICS AND DISSEMINATION: This review does not involve any human participants and therefore ethical approval will not be required. We will publish the protocol as well as the findings in any relevant journal and various media namely conferences; symposia, local and international health stakeholders. PROSPERO REGISTRATION NUMBER: CRD42020160012. CONCLUSION: Evidence from this review will provide synthesised evidence to the utilisation of CHWs in HIV services in SSA.

The roles, responsibilities and perceptions of community health workers and ward-based primary health care outreach teams: a scoping review.

BACKGROUND: Community health workers play important roles in rural primary health care settings. They work within ward-based primary health care outreach teams yet their roles are not always clearly defined and operationalized. There is thus a need to explore perceptions about the roles and responsibilities of community health workers. OBJECTIVE: To investigate the roles, responsibilities and effectiveness of community health workers working within ward-based primary health care outreach teams. METHOD: A scoping review of the published peer reviewed literature on community health workers working in ward-based primary health care outreach teams within low and middle-income countries was conducted. The following five electronic databases were searched: EBSCOhost, Google Scholar, Science Direct, EMBASE, PubMed, and Clinical key. Out of 69,969 identified articles, 31 met the inclusion criteria. The majority of the studies were from South Africa. RESULTS: Both positive and negative perceptions were reported. Suggestions for improvements were also put forward. Positive factors included: ongoing training and up skilling; collaboration and trust building with other health care workers; mentoring and supervision; motivation and recognition, and incentives and remuneration. Negative factors covered: inadequate mentorship and poor supervision; role conflict; lack of support; poor remuneration; inadequate manpower; poor knowledge, and insufficient training. The review identified the following as the roles and responsibilities of community health workers: conducting home visits; identifying vulnerable community groups; promoting health and wellness; increasing access to health care; contact tracing; delivering health education; giving counselling and psychosocial support, and providing preventive health services. CONCLUSION: The information available for community health workers in terms of their roles, responsibilities and effectiveness is inadequate, considering their roles and responsibilities in ward-based primary health care outreach teams. This lack of information constitutes barriers to effective service delivery, a common situation among this group of community health workers.

Soft Tissue Sepsis Places a Massive Burden on Regional and Tertiary Surgical Services in KZN Province South Africa.

BACKGROUND: Frequently, surgical intervention is needed to treat soft tissue sepsis (STS). Ideally, most STS should be managed at the lowest level of surgical care close to the patient's home and a well-functioning surgical service will be able to deliver this safely and effectively. This study interrogates the burden of STS in the province of KwaZulu-Natal and reviews at which level in the health system the operative management of STS is being dealt with. METHODS: This study describes the operations for soft tissue sepsis conducted at all regional and tertiary hospitals in KwaZulu-Natal province for the period of 1 July to 31 December 2015. All procedures for soft tissue sepsis were identified for closer review. RESULTS: Between 1 June and 31 December 2015, a total 6302 soft tissue-related procedures were performed in the regional and tertiary hospitals of KZN. The breakdown by anatomical region was as follows, 618 (9.8%) head and neck surgeries, 895 (14.2%) chest and back, 277 (4.4%) abdominal wall, 818 (13%) pelvis/perineal/buttock and 3070 (48.7%) extremity-related surgeries. There were a further 815 (12.9%) soft tissue-related procedures where the anatomical region was unspecified. Of the soft tissue procedures, 3943 (62.6%) were for the management of soft tissue sepsis. The anatomical regions involved included 316 (8%) head and neck, 485 (12.3%) chest and back, 194 (4.9%) abdominal wall, 589 (14.9%) pelvic, perineal and buttock, 2054 (52.1%) extremity and 365 unspecified operations. Peri-anal sepsis contributed 315 (8%), breast sepsis contributed to 372 (9.4%) of all soft tissue sepsis and amputations of extremities 658 (16.7%) of septic soft tissue procedures. CONCLUSION: There is a significant burden of soft tissue sepsis requiring surgical treatment each month at regional and tertiary hospitals in KZN. This is made up of breast sepsis, peri-anal sepsis and diabetic foot sepsis. This burden is being managed at an inappropriate level of care.

Spatial-temporal trends and risk factors for undernutrition and obesity among children (<5 years) in South Africa, 2008-2017: findings from a nationally representative longitudinal panel survey.

OBJECTIVES: To assess space-time trends in malnutrition and associated risk factors among children (<5 years) in South Africa. DESIGN: Multiround national panel survey using multistage random sampling. SETTING: National, community based. PARTICIPANTS: Community-based sample of children and adults. SAMPLE SIZE: 3254 children in wave 1 (2008) to 4710 children in wave 5 (2017). PRIMARY OUTCOMES: Stunting, wasting/thinness and obesity among children (<5). Classification was based on anthropometric (height and weight) z-scores using WHO growth standards. RESULTS: Between 2008 and 2017, a larger decline nationally in stunting among children (<5) was observed from 11.0% to 7.6% (p=0.007), compared with thinness/wasting (5.2% to 3.8%, p=0.131) and obesity (14.5% to 12.9%, p=0.312). A geographic nutritional gradient was observed with obesity more pronounced in the east of the country and thinness/wasting more pronounced in the west. Approximately 73% of districts had an estimated wasting prevalence below the 2025 target threshold of 5% in 2017 while 83% and 88% of districts achieved the necessary relative reduction in stunting and no increase in obesity respectively from 2012 to 2017 in line with 2025 targets. African ethnicity, male gender, low birth weight, lower socioeconomic and maternal/paternal education status and rural residence were significantly associated with stunting. Children in lower income and food-insecure households with young malnourished mothers were significantly more likely to be thin/wasted while African children, with higher birth weights, living in lower income households in KwaZulu-Natal and Eastern Cape were significantly more likely to be obese. CONCLUSIONS: While improvements in stunting have been observed, thinness/wasting and obesity prevalence remain largely unchanged. The geographic and sociodemographic heterogeneity in childhood malnutrition has implications for equitable attainment of global nutritional targets for 2025, with many districts having dual epidemics of undernutrition and overnutrition. Effective subnational-level public health planning and tailored interventions are required to address this challenge.

The roles, responsibilities and perceptions of community health workers and ward-based primary health care outreach teams (WBPHCOTs) in South Africa: a scoping review protocol.

BACKGROUND: Human resource for health (HRH) challenges jeopardise the South African health system, undermining the efforts made to curb the burden of disease. There is a demand for a category of health workers, which will meet the basic health needs of people at the grassroots level to ensure accessible, affordable health care using appropriate technologies acceptable to the recipients of care. The ward-based primary health care outreach teams are well placed to provide community-based primary health care services, which encompass activities in communities, households and referral networks with community-based providers. This study aims to elicit factors enabling or undermining the effectiveness of ward-based primary health care outreach teams in KwaZulu-Natal. METHODS: The search strategy of this scoping review will be guided by Arksey and O'Malley's scoping review methodology framework. The following electronic databases will be searched: PubMed, Google Scholar, Science Direct, Clinical key and from EBSCOhost platform and Dissertation via World Cat. The selection of study will involve three stages of screening. The principal author will conduct the title screen of articles from the databases and remove the duplicates. Two authors will independently conduct the abstract and full text screening, and articles that meet the eligibility criteria will be included for the study. Data will be extracted from the studies included, and the emerging themes will be analysed using NVIVO software. A quality assessment of the included studies will be determined through a mixed method appraisal tool (MMAT) version 2011. DISCUSSION: Ward-based primary health care outreach team (WBPHCOT) evidence, acceptability, preferences or practice effectiveness studies will be identified. Further expected results also include identification of knowledge gaps in primary health care practice as well as inform future research required. Findings will be disseminated electronically, in print and through peer presentation, conferences and congresses. Results from this scoping review will be useful to inform local and the South Africa National Health Insurance programme managers concerning the impact ward-based primary health care outreach teams have on the national health care system and on the health of the population.

The Operative Output of District Hospitals in KwaZulu-Natal Province is Heavily Skewed Toward Obstetrical Care.

INTRODUCTION: District hospitals are key to providing universal coverage of essential surgery and for strengthening surgical care in general. This audit set out to quantify the surgical output of all the district hospitals in KwaZulu-Natal Province (KZN) over a 6-month period to see whether district hospitals were delivering the surgical care they are expected to deliver. RESULTS: There were a total of 18,871 operations performed at 37 district hospitals in KwaZulu-Natal from July to December 2015. The number of operations per hospital varied widely between 2150 at a single large district hospital and 68 at a small district hospital, respectively. Surgical operations for obstetrical conditions made up by far the majority of operations at 57%, with gynecological operations making up the second highest at 15%. Only 12% of operations were for general surgical conditions. With regards to the bellwether procedures, 96.1% of these were cesarean sections, 2.1% were laparotomies and 1.8% were ORIFs. For almost all the 37 hospitals, the percentage of laparotomies and ORIFs performed was small to negligible, while the percentage of cesarean sections performed was high. The number of bellwether operations performed per 100,000 population was much higher than the number of general surgical or orthopedic operations performed, primarily because of the preponderance of cesarean sections conducted in each hospital. We observed a strong and significant positive correlation (+0.691, 95% CI +0.538 to +0.800, p < 0.001) between increasing distance to nearest regional referral hospital and rate of laparotomies and ORIF procedures performed. CONCLUSIONS: The surgical output of district hospitals in KZN is heavily skewed toward obstetrics and gynecology. Further work is required to understand the reasons for this, but the current data imply that district hospitals are not delivering surgical and orthopedic care at district hospitals in KwaZulu-Natal.

Defining and Negotiating the Social Value of Research in Public Health Facilities: Perceptions of Stakeholders in a Research-Active Province of South Africa.

This article reports on qualitative research conducted in KwaZulu-Natal, South Africa, among researchers and gate-keepers of health facilities in the province. Results suggest disparate but not irreconcilable perceptions of the social value of research in provincial health facilities. This study found that researchers tended to emphasize the contribution of research to the generation of knowledge and to the health of future patients while gate-keepers of health facilities tended to emphasize its contribution to the healthcare system and to current patients. Furthermore, relations between research stakeholders were perceived to be somewhat fragile, making it difficult for stakeholders to achieve consensus about the social value of research, as well as on ways to maximize value. Interventions to negotiate a shared perspective on the social value of research would appear to be warranted, and the findings of this study suggest some focus areas for such intervention.

A hospital based surveillance system to assess the burden of trauma in KwaZulu-Natal Province South Africa.

INTRODUCTION: In response to the ongoing excessive burden of trauma in South Africa the Data Management and Epidemiology Units of the Department of Health in conjunction with a group of trauma specialists developed a number of trauma data variables for inclusion on the routine District Health Information System (DHIS). The aim of this study is to describe the process followed and review the 2012-2014 data. METHODOLOGY: The variables collected included: total patient numbers assessed in the emergency room with a diagnosis of trauma; the mechanisms of trauma (blunt assault, motor vehicle accident, pedestrian vehicle accident, stab, gunshot wound, other); any trauma patient admitted to a health facility ward/ICU for longer than 12h; and whether the patient required transfer to a higher centre of care. All trauma deaths in hospital were recorded. The severity of trauma was measured using the Emergency Medical Services (EMS) classification of blue code (dead), red code (stretcher case with deranged physiology), yellow code (stretcher case with normal physiology) and green code (able to walk with normal physiology. The DHIS trauma data from April 2012 to March 2014 was reviewed. RESULTS: There were 197,219 emergency room visits for trauma in KZN in the 2013/2014 financial year. This constitutes 27.0% of all emergency room visits. The ratio of intentional to non-intentional injury is 45:55. There were 18,716 admissions to public sector hospitals for trauma in KZN in the 2013/2014 financial year. This constitutes 2.4% of all admissions in the province. There were 1045 inpatient deaths due to trauma in the same period, constituting 2.5% of all inpatient deaths. The overall rate of trauma in KZN was 17 per 1000 population. CONCLUSION: The adapted DHIS has successfully collected essential data that quantify the hospital burden of trauma in KZN province. This has provided the most complete overview of the burden of trauma in the Province. These trauma indicators should remain a permanent part of the DHIS to allow planners to track the trauma epidemic and to institute informed management strategies.

Incentives and enablers to improve adherence in tuberculosis.

BACKGROUND: Patient adherence to medications, particularly for conditions requiring prolonged treatment such as tuberculosis (TB), is frequently less than ideal and can result in poor treatment outcomes. Material incentives to reward good behaviour and enablers to remove economic barriers to accessing care are sometimes given in the form of cash, vouchers, or food to improve adherence. OBJECTIVES: To evaluate the effects of material incentives and enablers in patients undergoing diagnostic testing, or receiving prophylactic or curative therapy, for TB. SEARCH METHODS: We undertook a comprehensive search of the Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; LILACS; Science Citation Index; and reference lists of relevant publications up to 5 June 2015. SELECTION CRITERIA: Randomized controlled trials of material incentives in patients being investigated for TB, or on treatment for latent or active TB. DATA COLLECTION AND ANALYSIS: At least two review authors independently screened and selected studies, extracted data, and assessed the risk of bias in the included trials. We compared the effects of interventions using risk ratios (RR), and presented RRs with 95% confidence intervals (CI). The quality of the evidence was assessed using GRADE. MAIN RESULTS: We identified 12 eligible trials. Ten were conducted in the USA: in adolescents (one trial), in injection drug or cocaine users (four trials), in homeless adults (three trials), and in prisoners (two trials). The remaining two trials, in general adult populations, were conducted in Timor-Leste and South Africa. Sustained incentive programmesOnly two trials have assessed whether material incentives and enablers can improve long-term adherence and completion of treatment for active TB, and neither demonstrated a clear benefit (RR 1.04, 95% CI 0.97 to 1.14; two trials, 4356 participants; low quality evidence). In one trial, the incentive, given as a daily hot meal, was not well received by the population due to the inconvenience of attending the clinic at midday, whilst in the other trial, nurses distributing the vouchers chose to "ration" their distribution among eligible patients, giving only to those whom they felt were most deprived.Three trials assessed the effects of material incentives and enablers on completion of TB prophylaxis with mixed results (low quality evidence). A large effect was seen with regular cash incentives given to drug users at each clinic visit in a setting with extremely low treatment completion in the control group (treatment completion 52.8% intervention versus 3.6% control; RR 14.53, 95% CI 3.64 to 57.98; one trial, 108 participants), but no effects were seen in one trial assessing a cash incentive for recently released prisoners (373 participants), or another trial assessing material incentives offered by parents to teenagers (388 participants). Single once-only incentivesHowever in specific populations, such as recently released prisoners, drug users, and the homeless, trials show that material incentives probably do improve one-off clinic re-attendance for initiation or continuation of anti-TB prophylaxis (RR 1.58, 95% CI 1.27 to 1.96; three trials, 595 participants; moderate quality evidence), and may increase the return rate for reading of tuberculin skin test results (RR 2.16, 95% CI 1.41 to 3.29; two trials, 1371 participants; low quality evidence). Comparison of different types of incentivesSingle trials in specific sub-populations suggest that an immediate cash incentive may be more effective than delaying the incentive until completion of treatment (RR 1.11, 95% CI 0.98 to 1.24; one trial, 300 participants; low quality evidence), cash incentives may be more effective than non-cash incentives (completion of TB prophylaxis: RR 1.26, 95% CI 1.02 to 1.56; one trial, 141 participants; low quality evidence; return for skin test reading: RR 1.13, 95% CI 1.07 to 1.19; one trial, 652 participants; low quality evidence); and higher cash incentives may be more effective than lower cash incentives (RR 1.08, 95% CI 1.01 to 1.16; one trial, 404 participants; low quality evidence). AUTHORS' CONCLUSIONS: Material incentives and enablers may have some positive short term effects on clinic attendance, particularly for marginal populations such as drug users, recently released prisoners, and the homeless, but there is currently insufficient evidence to know if they can improve long term adherence to TB treatment.

Economic support to improve tuberculosis treatment outcomes in South Africa: a qualitative process evaluation of a cluster randomized controlled trial.

BACKGROUND: Poverty undermines the adherence of patients to tuberculosis treatment. A pragmatic cluster randomized controlled trial was conducted to investigate the extent to which economic support in the form of a voucher would improve patients' adherence to treatment, and their treatment outcomes. Although the trial showed a modest improvement in the treatment success rates of the intervention group, this was not statistically significant, due in part to the low fidelity to the trial intervention. A qualitative process evaluation, conducted in the final few months of the trial, explained some of the factors that contributed to this low fidelity. METHODS: In-depth interviews were conducted with patients who received vouchers, nurses in intervention clinics, personnel in shops who administered the vouchers, and managers of the TB Control Programme. These interviews were analyzed thematically. RESULTS: The low fidelity to the trial intervention can be explained by two main factors. The first was nurses' tendency to 'ration' the vouchers, only giving them to the most needy of eligible patients and leaving out those eligible patients whom they felt were financially more comfortable. The second was logistical issues related to the administration of the voucher as vouchers were not always available for patients on their appointed clinic dates, necessitating further visits to the clinics which they were not always able to make. CONCLUSIONS: This process evaluation identifies some of the most important factors that contributed to the results of this pragmatic trial. It highlights the value of process evaluations as tools to explain the results of randomized trials and emphasizes the importance of implementers as 'street level bureaucrats' who may profoundly affect the way an intervention is administered. TRIAL REGISTRATION: Current Controlled Trials ISRCTN50689131, registered 21 April 2009. The trial protocol is available at the following web address: http://www.hst.org.za/publications/study-protocol-economic-incentives-improving-clinical-outcomes-patients-tb-south-africa.

Economic support to improve tuberculosis treatment outcomes in South Africa: a pragmatic cluster-randomized controlled trial.

BACKGROUND: Poverty undermines adherence to tuberculosis treatment. Economic support may both encourage and enable patients to complete treatment. In South Africa, which carries a high burden of tuberculosis, such support may improve the currently poor outcomes of patients on tuberculosis treatment. The aim of this study was to test the feasibility and effectiveness of delivering economic support to patients with pulmonary tuberculosis in a high-burden province of South Africa. METHODS: This was a pragmatic, unblinded, two-arm cluster-randomized controlled trial, where 20 public sector clinics acted as clusters. Patients with pulmonary tuberculosis in intervention clinics (n = 2,107) were offered a monthly voucher of ZAR120.00 (approximately US$15) until the completion of their treatment. Vouchers were redeemed at local shops for foodstuffs. Patients in control clinics (n = 1,984) received usual tuberculosis care. RESULTS: Intention to treat analysis showed a small but non-significant improvement in treatment success rates in intervention clinics (intervention 76.2%; control 70.7%; risk difference 5.6% (95% confidence interval: -1.2%, 12.3%), P = 0.107). Low fidelity to the intervention meant that 36.2% of eligible patients did not receive a voucher at all, 32.3% received a voucher for between one and three months and 31.5% received a voucher for four to eight months of treatment. There was a strong dose-response relationship between frequency of receipt of the voucher and treatment success (P <0.001). CONCLUSIONS: Our pragmatic trial has shown that, in the real world setting of public sector clinics in South Africa, economic support to patients with tuberculosis does not significantly improve outcomes on treatment. However, the low fidelity to the delivery of our voucher meant that a third of eligible patients did not receive it. Among patients in intervention clinics who received the voucher at least once, treatment success rates were significantly improved. Further operational research is needed to explore how best to ensure the consistent and appropriate delivery of such support to those eligible to receive it.