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Research Article
Jamie Murdoch
University of East Anglia
Corresponding Author
ORCiD: https://orcid.org/0000-0002-9021-3629
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Background
Despite progress towards meeting End TB strategy targets for reducing tuberculosis (TB) incidence and deaths by 2035, South Africa remains among the top ten high-burden tuberculosis countries globally. A large challenge lies in how policies to improve detection, diagnosis and treatment completion interact with social and structural drivers of TB. Detailed understanding and theoretical development of the contextual determinants of problems in TB care is required for developing effective interventions. This article reports findings from the pre-implementation phase of a study of TB care in South Africa, contributing to ASSET - a broader five-year research programme developing and evaluating health system strengthening interventions in sub-Saharan Africa. The study aimed to develop hypothetical propositions regarding the contextual determinants of problems in TB care to inform intervention development to reduce TB deaths and incidence whilst ensuring the delivery of quality integrated, respectful person-centred care.
Methods
Theory-building case study design using the Context and Implementation of Complex Interventions (CICI) framework to identify contextual determinants of problems in TB care. Between February and November 2019, we used mixed methods in six public- sector primary healthcare facilities and one public sector hospital serving impoverished urban and rural communities in the Amajuba district of KwaZulu-Natal province, South Africa. Qualitative data included stakeholder interviews, observations and documentary analysis. Quantitative data included routine data on sputum testing and TB deaths. Data were inductively analysed and mapped onto the seven CICI contextual domains.
Results
Delayed diagnosis was caused by interactions between fragmented healthcare provision; limited resources; verticalised care provision; poor TB screening, sputum collection and record-keeping. One nurse responsible for TB care, limited integration with other conditions, and policy focus on treatment adherence contributed to staff stress and limited focus on patients’ psychosocial needs. Patients were lost to follow up due to discontinuity of information, poverty, employment restrictions and limited support for treatment side-effects. Infection control measures appeared to be compromised by efforts to integrate care.
Conclusion
Interventions are required that strengthen early detection, diagnosis, treatment initiation and completion. TB policy needs to promote person-centred support for healthcare professionals and patients through the TB treatment pathway.
Keywords
Tuberculosis, health systems strengthening, primary healthcare, person-centred care, context
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CURRENT STATUS: Under Review
Version 1
Posted 25 Jan, 2021
No community comments so far
Editorial decision: Minor revision
On 03 Mar, 2021
Review #1 received
Received 28 Feb, 2021
Review #2 received
Received 18 Feb, 2021
Reviewer #2 agreed
On 07 Feb, 2021
Reviewer #1 agreed
On 02 Feb, 2021
Reviewers invited
Invitations sent on 01 Feb, 2021
Editor assigned
On 23 Jan, 2021
Editor invited
On 23 Jan, 2021
Submission checks complete
On 21 Jan, 2021
First submitted
On 19 Jan, 2021
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Subject Areas
Infectious Diseases
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A new preprint design is coming!
We have improved readability, clarity, accessibility, and opportunities for engagement.
This preprint is under consideration at Infectious Diseases of Poverty. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research Article
Jamie Murdoch
University of East Anglia
Corresponding Author
ORCiD: https://orcid.org/0000-0002-9021-3629
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Under Review
Version 1
Posted 25 Jan, 2021
No community comments so far
Editorial decision: Minor revision
On 03 Mar, 2021
Review #1 received
Received 28 Feb, 2021
Review #2 received
Received 18 Feb, 2021
Reviewer #2 agreed
On 07 Feb, 2021
Reviewer #1 agreed
On 02 Feb, 2021
Reviewers invited
Invitations sent on 01 Feb, 2021
Editor assigned
On 23 Jan, 2021
Editor invited
On 23 Jan, 2021
Submission checks complete
On 21 Jan, 2021
First submitted
On 19 Jan, 2021
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
Subject Areas
Infectious Diseases
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Background
Despite progress towards meeting End TB strategy targets for reducing tuberculosis (TB) incidence and deaths by 2035, South Africa remains among the top ten high-burden tuberculosis countries globally. A large challenge lies in how policies to improve detection, diagnosis and treatment completion interact with social and structural drivers of TB. Detailed understanding and theoretical development of the contextual determinants of problems in TB care is required for developing effective interventions. This article reports findings from the pre-implementation phase of a study of TB care in South Africa, contributing to ASSET - a broader five-year research programme developing and evaluating health system strengthening interventions in sub-Saharan Africa. The study aimed to develop hypothetical propositions regarding the contextual determinants of problems in TB care to inform intervention development to reduce TB deaths and incidence whilst ensuring the delivery of quality integrated, respectful person-centred care.
Methods
Theory-building case study design using the Context and Implementation of Complex Interventions (CICI) framework to identify contextual determinants of problems in TB care. Between February and November 2019, we used mixed methods in six public- sector primary healthcare facilities and one public sector hospital serving impoverished urban and rural communities in the Amajuba district of KwaZulu-Natal province, South Africa. Qualitative data included stakeholder interviews, observations and documentary analysis. Quantitative data included routine data on sputum testing and TB deaths. Data were inductively analysed and mapped onto the seven CICI contextual domains.
Results
Delayed diagnosis was caused by interactions between fragmented healthcare provision; limited resources; verticalised care provision; poor TB screening, sputum collection and record-keeping. One nurse responsible for TB care, limited integration with other conditions, and policy focus on treatment adherence contributed to staff stress and limited focus on patients’ psychosocial needs. Patients were lost to follow up due to discontinuity of information, poverty, employment restrictions and limited support for treatment side-effects. Infection control measures appeared to be compromised by efforts to integrate care.
Conclusion
Interventions are required that strengthen early detection, diagnosis, treatment initiation and completion. TB policy needs to promote person-centred support for healthcare professionals and patients through the TB treatment pathway.
Figure 1
Figure 2
This is a list of supplementary files associated with this preprint. Click to download.
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