Potential facilitators and inhibitors to the implementation and sustainability of the community-based tuberculosis care interventions. A case study from Moshupa, Botswana.

BACKGROUND: Eliminating Tuberculosis is one of the targets of Sustainable Development Goal Three. Decentralizing TB care beyond health facilities by leveraging community involvement is crucial for safeguarding effective tuberculosis care. In this study, we explored potential facilitators and inhibitors of the implementation and sustainability of community-based interventions for the prevention and treatment of TB in the Moshupa district, Botswana. METHODS: This study adopted a qualitative approach using a collective case design. An interpretive paradigm based on relativist ontology and subjectivist epistemology along with abductive research logic was used. The study enrolled treatment supporters of tuberculosis patients diagnosed with drug-susceptible tuberculosis between January 2019 and December 2019 in Moshupa Village for semi-structured interviews, Health care professionals for in-depth interviews, and e community leaders for focus group discussions. Clinic-based observations in Mma-Seetsele clinic were also conducted to corroborate the participants' views. The data collected was analyzed using the NVivo version 12 software package, and statements of the participants were presented as quotes to substantiate the issues discussed. RESULTS: This study highlighted effective partnerships between health services and external stakeholders, community empowerment, and the availability of policies and standard operating procedures as facilitators of community TB implementation and sustainability. However, Insufficient funding, low service provider training, policies not embracing age and educational eligibility for treatment supporters, shortage of equipment, medicines, and supplies, inadequate transport availability and incentives to meet clients' basic needs, paper-based systems, inadequate supervision, incomplete data reporting, and low service quality affected the Community TB program efficacy and sustainability in Moshupa. We also found that there was low service provider motivation and retention and that clients had low trust in treatment supporters. CONCLUSION: The findings of this study imply that the operational effectiveness of the community TB care approach to disease elimination is compromised; therefore, initiatives addressing the key components, including the availability of resources, governance arrangements and supportive systems for community health workers, are required for successful community TB implementation and sustainability.

Mapping the effectiveness of the community tuberculosis care programs: a systematic review.

BACKGROUND: Tuberculosis is a significant global public health threat, especially in countries with limited resources. To improve tuberculosis care, the World Health Organization emphasizes the importance of considering a TB patient's journey across a variety of connected settings and facilities. A systematic review was conducted to map previously conducted studies to identify existing community TB implementation models, their effectiveness on cost, and treatment outcomes. METHODS: Systematic search through various electronic databases MEDLINE, EBSCO (PsycINFO and CINAHL), Cochrane Library, EMBASE, WHO Regional Databases, gray literature, and hand-searched bibliographies was performed. Articles published in English between the years 2000 and 2022 with a substantial focus on community TB implementation models were considered for inclusion. Studies were excluded if the intervention was purely facility-based and those focusing exclusively on qualitative assessments. Two reviewers used standardized methods to screen titles, abstracts, and data charting. Included studies were assessed for quality using ROBINS-I and ROB 2. Analysis of study results uses a PRISMA flow diagram and quantitative approach. RESULTS: A total of 6982 articles were identified with 36 meeting the eligibility criteria for analysis. Electronic medication monitors showed an increased probability of treatment success rate (RR 1.0-4.33 and the 95% CI 0.98-95.4) in four cohort studies in low- and middle-income countries with the incremental cost-effectiveness of $434. Four cohort studies evaluating community health worker direct observation therapy in low- and middle-income countries showed a treatment success risk ratio of up to 3.09 with a 95% CI of 0.06-7.88. (32,41,43,48) and incremental cost-effectiveness up to USS$410. Moreover, four comparative studies in low- and middle-income countries showed family directly observed treatment success risk ratio up to 9.07, 95% CI of 0.92-89.9. Furthermore, four short message service trials revealed a treatment success risk ratio ranging from 1.0 to 1.45 (95% CI fell within these values) with a cost-effectiveness of up to 350I$ compared to standard of care. CONCLUSIONS: This review illustrates that community-based TB interventions such as electronic medication monitors, community health worker direct observation therapy, family directly observed treatment, and short message service can substantially bolster efficiency and convenience for patients and providers while reducing health system costs and improving clinical outcomes.

Patient and health system determinants of experiences of care at primary health care clinics in eThekwini, KwaZulu-Natal, 2018.

BACKGROUND: Respect for persons includes three sub-elements: dignity, autonomy and confidentiality, whilst client orientation has four sub-elements: prompt attention, quality of basic amenities, access to social support for hospitalised individuals and choice of health providers. AIM: This study sought to determine patient and health system determinants of experiences of care. SETTING: Study was conducted at primary health care clinics in eThekwini, KwaZula-Natal. METHODS: A self-administered questionnaire was used to collect data from 384 patients who received ambulatory care at six primary health care facilities (three community healthcare centres and three clinics) between June 2018 and November 2018. RESULTS: Three hundred and sixty nine respondents were included in the study. Eighty one percent (299) of the respondents were female, 67.2% (248) were single and 89.7% (331) were black Africans. Fifty (13.6%) respondents reported their health status to be poor, whilst 47 (12.5%) reported excellent health, with the majority (72.0%) reporting 'good' or 'fair' health. The patients' experience score for the study population was 89.0% (IQR 81% - 98%). Patients who attended clinics had a 6.53 (p 0.001) times increased odds of reporting good patients' experience score compared with patients who attended community healthcare centres. Although ideal clinic status had a positive association with patients' experience score (odds ration [OR]: 1.75; p 0.05) this was not significant. CONCLUSION: Patients attending clinics had a better experience compared with community health centres. Ideal clinic status showed a positive but not statistical significant association with good patient experiences. This may suggest that factors other than structural improvements play an important role in patients' experience.

Epidemiology of patient safety incidents in a long-term rehabilitative hospital in KwaZulu-Natal, South Africa (April 2011 to March 2016).

BACKGROUND: Patient safety is a key priority of the National Department of Health. Despite the publication of legislation and other measures to address patient safety incidents (PSIs) there are a paucity of studies relating to patient safety at the different levels of hospitals. OBJECTIVES: To determine the epidemiology (incidence, nature and root causes) of PSIs at a long-term rehabilitative hospital between April 2011 and March 2016. METHOD: Data were collected through a review and analysis of routinely collected hospital information on patient records and from the PSI register, as well as minutes of adverse health events meetings, quality assurance reports and patient complaints register. RESULTS: A total or 4.12 PSIs per 10 000 inpatient days were reported. Approximately 52% of the adverse health events occurred in females with most of the adverse health events occurring in the 50-59 years category: 96% being reported during the day and 33% within the shift change. Pressure ulcers, falls, injury, hospital acquired infections and medication error were the most commonly reported PSIs. Patient factors were listed as the most common root cause for the PSIs. CONCLUSION: The study shows a low reporting rate of PSIs whilst showing a diverse pattern of PSIs over a period of 5 years. There is a need for active change management in order to establish a blame-free culture and learning environment to improve reporting of PSI. A comprehensive quality improvement intervention addressing patients, their families and staff is essential to minimise PSI and its consequences.

Perceptions of hospital staff on the performance of Quality Improvement teams in the regional referral hospitals in Tanzania: A cross sectional study.

BACKGROUND: To ensure patient-centered quality care for all citizens, Quality Improvement (QI) teams have been established across all public hospitals in Tanzania. However, little is known about how hospital staff perceive the performance of hospital QI teams in Tanzania. This study assessed the perceptions of hospital staff of the performance of QI teams in selected regional referral hospitals in Tanzania. METHODS: This cross-sectional study was conducted in four selected regional referral hospitals between April and August 2018. A self-administered questionnaire was used to collect data from 385 hospital staff in the selected hospitals. Measures of central tendency, proportions and frequencies were used to assess level of perception of hospital staff. Bivariate and multivariate logistic regression was used to test the association between the perceptions of hospital staff of the performance of QI teams and their socio-demographic factors. RESULTS: The overall mean perception score of the performance of QI teams was 4.84 ± 1.25. Hospital staff aged 35 and over (n = 130; 68%), female hospital staff (n = 144; 64%), staff in clinical units (n = 136; 63%) and staff with post-secondary education (n = 175; 63%) perceived that the performance of QI teams was good. Improved hospital cleanliness was viewed as strength of QI teams, whilst inadequate sharing of information and inadequate reduction in patient waiting time were considered as weaknesses of QI team performance. Bivariate and multivariate logistic regression analyses showed that there was no statistical association between the perceptions of hospital staff and their socio-demographic characteristics. CONCLUSION: The overall perception of hospital staff of the performance of QI teams was good, with the main limitation being sharing of hospital QI plans with hospital staff. Hospital staff should be involved in the development and implementation of hospital QI plans, which would promote a positive perception of staff of the performance of QI teams and enhance sustainability of QI teams.

Sustainability of quality improvement teams in selected regional referral hospitals in Tanzania.

OBJECTIVE: The aim of this study was to determine the sustainability of hospital quality improvement teams and to assess factors influencing their sustainability in the regional referral hospital in Tanzania. DESIGN: A cross-sectional study was conducted between April and August of 2018. SETTING AND PARTICIPANTS: The study was conducted in four selected regional referral hospitals in Tanzania. All members of the quality improvement teams available during the study period were recruited. INTERVENTION: Quality improvement teams and their activities. MAIN OUTCOME MEASURE: The primary outcome was sustainability total scores. The secondary outcomes were process, staff and organizational sustainability scores. The sustainability of quality improvement teams was assessed by using the National Health Service Institute for Innovation and Improvement Sustainability Model self-assessment tool. RESULTS: The overall mean sustainability score was 59.08 (95% CI: 53.69-64.46). Tanga Regional Referral Hospital had the highest mean sustainability score of 66.15 (95% CI: 55.12-77.18). Mbeya Regional Referral Hospital obtained the lowest mean sustainability score of 52.49 (95% CI: 42.96-62.01). The process domain had the highest proportionate mean sustainability score of 22.46 (95% CI: 20.58-24.33) across four hospitals. The staff domain recorded the lowest proportionate sustainability score of 27.28 (95% CI: 24.76-29.80). CONCLUSIONS: Perceived less involvement of senior leadership (hospital management teams) and clinical leadership (heads of clinical departments) and infrastructure limitation appeared to negatively affect the sustainability of the hospital quality improvement teams. Our study underscores the importance of establishing a permanent and fully resourced Quality Improvement Unit-with team members employed as full-time staff.

Health system challenges affecting HIV and tuberculosis integration at primary healthcare clinics in Durban, South Africa.

BACKGROUND: Tuberculosis (TB) is the most common presenting illness among people living with human immunodeficiency virus (HIV), with co-infection occurring in up to 60% of cases in South Africa. In line with international guidelines, South Africa has adopted an integrated model at primary healthcare level to provide HIV and TB services by the same healthcare provider at the same visit. AIM: The aim of the study was to conduct a rapid appraisal of integration of HIV and TB services at primary healthcare level in eThekwini District in 2015. SETTING: The study was conducted in 10 provincial primary healthcare clinics in the eThekwini Metropolitan Health District in KwaZulu-Natal Province. METHODS: An observational, cross-sectional study was conducted. Key informant interviews with operational managers and community health workers were conducted, as well as a review of registers and electronic databases for the period of January to March 2015. RESULTS: Two clinics complied with the mandated integrated model. Three clinics were partially integrated; while five clinics maintained the stand-alone model. Possible constraints included reorganisation of on-site location of services, drug provision, TB infection control and inadequate capacity building, while potential enablers comprised structural infrastructure, staffing ratios and stakeholder engagement. CONCLUSION: HIV and TB integration is suboptimal and will need to be improved by addressing the systemic challenges affecting health service delivery, including strengthening supervision, training and the implementation of a change management programme.

Health system challenges affecting HIV and tuberculosis integration at primary healthcare clinics in Durban, South Africa

Background: Tuberculosis (TB) is the most common presenting illness among people living with human immunodeficiency virus (HIV), with co-infection occurring in up to 60% of cases in South Africa. In line with international guidelines, South Africa has adopted an integrated model at primary healthcare level to provide HIV and TB services by the same healthcare provider at the same visit. Aim: The aim of the study was to conduct a rapid appraisal of integration of HIV and TB services at primary healthcare level in eThekwini District in 2015. Setting: The study was conducted in 10 provincial primary healthcare clinics in the eThekwini Metropolitan Health District in KwaZulu-Natal Province. Methods: An observational, cross-sectional study was conducted. Key informant interviews with operational managers and community health workers were conducted, as well as a review of registers and electronic databases for the period of January to March 2015. Results: Two clinics complied with the mandated integrated model. Three clinics were partially integrated; while five clinics maintained the stand-alone model. Possible constraints included reorganisation of on-site location of services, drug provision, TB infection control and inadequate capacity building, while potential enablers comprised structural infrastructure, staffing ratios and stakeholder engagement. Conclusion: HIV and TB integration is suboptimal and will need to be improved by addressing the systemic challenges affecting health service delivery, including strengthening supervision, training and the implementation of a change management programme

Professional nurses' perceptions and experiences with the implementation of an integrated chronic care model at primary healthcare clinics in South Africa.

BACKGROUND: An integrated chronic disease management model has been implemented across primary healthcare clinics in order to transform the delivery of services for patients with chronic diseases. The sustainability and rapid scale-up of the model is dependent on positive staff perceptions and experiences. OBJECTIVES: The aim of the study was to determine the perceptions and experiences of professional nurses with the integrated chronic care model that has been implemented. METHOD: A cross-sectional descriptive survey utilising a self-administered questionnaire was conducted amongst all professional nurses who were involved in delivering primary healthcare services at the 42 implementing facilities in September 2014. Each facility has between four and eight professional nurses providing a service daily at the facilitiesResults: A total of 264 professional nurses participated in the survey. Prior to the implementation, 34% (91) of the staff perceived the model to be an added programme, whilst 36% (96) of the staff experienced an increased workload. Staff noted an improved process of care, better level of interaction with patients, improved level of knowledge and better teamwork coupled with an improved level of satisfaction with the work environment at the clinic after implementation of the integrated chronic disease model. CONCLUSION: Professional nurses have a positive experience with the implementation of the integrated chronic disease management model.

Professional nurses' perceptions and experiences with the implementation of an integrated chronic care model at primary healthcare clinics in South Africa

Background: An integrated chronic disease management model has been implemented across primary healthcare clinics in order to transform the delivery of services for patients with chronic diseases. The sustainability and rapid scale-up of the model is dependent on positive staff perceptions and experiences.Objectives: The aim of the study was to determine the perceptions and experiences of professional nurses with the integrated chronic care model that has been implemented.Method: A cross-sectional descriptive survey utilising a self-administered questionnaire was conducted amongst all professional nurses who were involved in delivering primary healthcare services at the 42 implementing facilities in September 2014. Each facility has between four and eight professional nurses providing a service daily at the facilities Results: A total of 264 professional nurses participated in the survey. Prior to the implementation, 34% (91) of the staff perceived the model to be an added programme, whilst 36% (96) of the staff experienced an increased workload. Staff noted an improved process of care, better level of interaction with patients, improved level of knowledge and better teamwork coupled with an improved level of satisfaction with the work environment at the clinic after implementation of the integrated chronic disease model.Conclusion: Professional nurses have a positive experience with the implementation of the integrated chronic disease management model

Impact of Lean on patient cycle and waiting times at a rural district hospital in KwaZulu-Natal.

BACKGROUND: Prolonged waiting time is a source of patient dissatisfaction with health care and is negatively associated with patient satisfaction. Prolonged waiting times in many district hospitals result in many dissatisfied patients, overworked and frustrated staff, and poor quality of care because of the perceived increased workload. AIM: The aim of the study was to determine the impact of Lean principles techniques, and tools on the operational efficiency in the outpatient department (OPD) of a rural district hospital. SETTING: The study was conducted at the Catherine Booth Hospital (CBH) - a rural district hospital in KwaZulu-Natal, South Africa. METHODS: This was an action research study with pre-, intermediate-, and post-implementation assessments. Cycle and waiting times were measured by direct observation on two occasions before, approximately two-weekly during, and on two occasions after Lean implementation. A standardised data collection tool was completed by the researcher at each of the six key service nodes in the OPD to capture the waiting times and cycle times. RESULTS: All six service nodes showed a reduction in cycle times and waiting times between the baseline assessment and post-Lean implementation measurement. Significant reduction was achieved in cycle times (27%; p < 0.05) and waiting times (from 11.93 to 10 min; p = 0.03) at the Investigations node. Although the target reduction was not achieved for the Consulting Room node, there was a significant reduction in waiting times from 80.95 to 74.43 min, (p < 0.001). The average efficiency increased from 16.35% (baseline) to 20.13% (post-intervention). CONCLUSION: The application of Lean principles, tools and techniques provides hospital managers with an evidence-based management approach to resolving problems and improving quality indicators.

Implications of the introduction of laboratory demand management at primary care clinics in South Africa on laboratory expenditure.

BACKGROUND: Diagnostic health laboratory services are regarded as an integral part of the national health infrastructure across all countries. Clinical laboratory tests contribute substantially to health system goals of increasing quality of care and improving patient outcomes. OBJECTIVES: This study aimed to analyse current laboratory expenditures at the primary healthcare (PHC) level in South Africa as processed by the National Health Laboratory Service and to determine the potential cost savings of introducing laboratory demand management. METHODS: A retrospective cross-sectional analysis of laboratory expenditures for the 2013/2014 financial year across 11 pilot National Health Insurance health districts was conducted. Laboratory expenditure tariff codes were cross-tabulated to the PHC essential laboratory tests list (ELL) to determine inappropriate testing. Data were analysed using a Microsoft Access database and Excel software. RESULTS: Approximately R35 million South African Rand (10%) of the estimated R339 million in expenditures was for tests that were not listed within the ELL. Approximately 47% of expenditure was for laboratory tests that were indicated in the algorithmic management of patients on antiretroviral treatment. The other main cost drivers for non-ELL testing included full blood count and urea, as well as electrolyte profiles usually requested to support management of patients on antiretroviral treatment. CONCLUSIONS: Considerable annual savings of up to 10% in laboratory expenditure are possible at the PHC level by implementing laboratory demand management. In addition, to achieve these savings, a standardised PHC laboratory request form and some form of electronic gatekeeping system that must be supported by an educational component should be implemented.

Sustainability of the integrated chronic disease management model at primary care clinics in South Africa.

BACKGROUND: An integrated chronic disease management (ICDM) model consisting of four components (facility reorganisation, clinical supportive management, assisted self-supportive management and strengthening of support systems and structures outside the facility) has been implemented across 42 primary health care clinics in South Africa with a view to improve the operational efficiency and patient clinical outcomes. AIM: The aim of this study was to assess the sustainability of the facility reorganisation and clinical support components 18 months after the initiation. SETTING: The study was conducted at 37 of the initiating clinics across three districts in three provinces of South Africa. METHODS: The National Health Service (NHS) Institute for Innovation and Improvement Sustainability Model (SM) self-assessment tool was used to assess sustainability. RESULTS: Bushbuckridge had the highest mean sustainability score of 71.79 (95% CI: 63.70-79.89) followed by West Rand Health District (70.25 (95% CI: 63.96-76.53)) and Dr Kenneth Kaunda District (66.50 (95% CI: 55.17-77.83)). Four facilities (11%) had an overall sustainability score of less than 55. CONCLUSION: The less than optimal involvement of clinical leadership (doctors), negative staff behaviour towards the ICDM, adaptability or flexibility of the model to adapt to external factors and infrastructure limitation have the potential to negatively affect the sustainability and scale-up of the model.

Improving the quality of nurse clinical documentation for chronic patients at primary care clinics: A multifaceted intervention.

BACKGROUND: Deficiencies in record keeping practices have been reported at primary care level in the public health sector in South Africa. These deficiencies have the potential to negatively impact patient health outcomes as the break in information may hinder continuity of care. This disruption in information management has particular relevance for patients with chronic diseases. OBJECTIVES: The aim of this study was to establish if the implementation of a structured clinical record (SCR) as an adjunct tool to the algorithmic guidelines for chronic disease management improved the quality of clinical records at primary care level. METHOD: A quasi-experimental study (before and after study with a comparison group) was conducted across 30 primary health care clinics (PHCs) located in three districts in South Africa. Twenty PHCs that received the intervention were selected as intervention clinics and 10 facilities were selected as comparison facilities. The lot quality assurance sampling (LQAS) method was used to determine the number of records required to be reviewed per diagnostic condition per facility. RESULTS: There was a a statistically significant increase in the percentage of clinical records achieving compliance to the minimum criteria from the baseline to six months post-intervention for both HIV patients on antiretroviral treatment and patients with non-communicable diseases (hypertension and diabetes). CONCLUSIONS: A multifaceted intervention using a SCR to supplement the educational outreach component (PC 101 training) has demonstrated the potential for improving the quality of clinical records for patients with chronic diseases at primary care clinics in South Africa.