Operational research on implementation of tuberculosis guidelines in
Mozambique
Brouwer, M.A.
Publication date
2015
Document Version
Final published version
Link to publication
Citation for published version (APA):
Brouwer, M. A. (2015). Operational research on implementation of tuberculosis guidelines in
Mozambique.
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8. General!discussion!
The!translation!of!research!evidence,!often!presented!in!the!form!of!guidelines,!into!health!care!practice! poses! considerable! challenges.! The! process! of! developing! these! guidelines! consists! of! several! steps:! composition! of! the! development! group,! the! development! itself,! dissemination,! implementation,! and! the! evaluation! of! the! guidelines.1! Through! several! case! studies! from! Mozambique! we! assessed! parts! of! this!
process!and!addressed!two!research!questions:!1)!How!can!assessment!of!guideline!implementation!and!its! evaluation!contribute!to!health!care!decisionPmaking?!and!2)!Which!factors!are!critical!for!failure!or!success! in! guideline! implementation?! We! further! discuss! remaining! challenges! and! implications! for! guideline! implementation!and!further!research.!
!
Role!of!routinely!available!data!in!guideline!implementation!evaluation!and!health!care!decision:making! Glasgow! states! that! the! translation! of! research! into! practice! is! often! slow! and! difficult! because! of! insufficient!attention!for!the!pragmatic!aspect!of!interventions:!does!it!work!under!usual!conditions?2!He! suggests!pragmatic!research!that!addresses!specific!practice!needs!and!questions,!is!relatively!simple,!and! has!attention!for!issues!of!health!care!workers,!policy!makers!and!patients,!amongst!others.!The!evaluation! of!guideline!implementation!can!contribute!to!the!identification!of!these!needs,!questions,!and!issues.!A! pragmatic!approach!in!such!evaluation!is!the!use!of!routinely!available!data.!! The!use!of!routinely!available!data!showed!that!some!delay!in!a!CD4+!cell!count!result!would!not!lead!to! missing!an!opportunity!to!initiate!ART!(chapter!2).!This!finding!presently!has!lost!its!relevance!because!the! ART! guidelines! were! revised! since! this! study! and! now! recommend! to! initiate! ART! in! all! HIVPinfected! TB! patients! as! soon! as! possible! irrespective! of! CD4+! cell! count.3! However,! the! finding! may! still! be! valid! for!
countries!that!wish!to!continue!using!CD4+!cell!count!for!reasons!such!as!priority!setting.!Furthermore,!new! evidence!emerged!showing!that!deferring!ART!until!TB!treatment!is!finished!does!not!affect!mortality!in! HIVPinfected!TB!patients!with!a!CD4+!cell!count!of!more!than!220!cells/µL!compared!with!initiation!of!ART! during!TB!treatment.4!This!finding!may!influence!future!recommendations!on!when!to!initiate!ART!in!HIVP
infected!TB!patients.!
The! use! of! routinely! available! data! also! showed! that! HIV! programmes! are! better! positioned! than! TB! programmes!to!assess!ART!coverage!(chapter!3).!In!addition!we!found!reporting!on!ART!coverage!at!the! same!time!the!TB!programme!reports!notified!TB!cases!provides!a!timely!but!incomplete!picture.!Despite! this!limitation,!the!global!recommendation!now!is!to!report!on!ART!coverage!at!the!same!time!as!reporting! TB!notifications.5!!
The! use! of! routinely! available! data! using! a! benchmark! tool! showed! potential! underPdiagnosis! of! smearP negative! pulmonary! and! extrapulmonary! TB! (chapter! 4).! The! tool! is! also! capable! of! assessing! potential! overPdiagnosis!as!Figure!8!shows.!
The! WHO! recognised! that! more! can! be! done! with! the! TB! data! collected! by! national! programmes! and! published! a! document! on! how! to! use! TB! data.6! Though! the! document! is! very! useful! for! national!
programmes!it!may!have!limited!value!for!local!TB!workers!because!of!the!methods!used.!Furthermore,!if! such!documents!came!with!readyPmade!tools!for!(part!of!the)!dataPanalysis!such!as!spreadsheets!or!apps! for! mobile! devices,! data! analysis! for! local! workers! would! be! much! easier.! The! advantage! of! developing! tools!is!that!these!would!be!useful!for!many!countries!because!almost!all!countries!record!and!report!TB! data!following!the!WHO!standard.5!One!of!the!tools!presented!in!the!document!on!using!TB!data!is!similar!
to!our!benchmark!tool.! !
!
Note:!the!black!lines!refer!to!the!values!of!the!whole!country!that!were!chosen!as!the!reference!value.!
!
Figure! 8! Benchmarking! data! for! selected! Mozambican! provinces! on! diagnosis! of! smear;negative! and! extrapulmonary!TB!2007;2009!
!
The!benchmark!tool!does!not!proof!underP!or!overPdiagnosis!but!alerts!TB!programme!staff!that!in!a!certain! setting! the! performance! is! different! from! similar! settings.! Further! assessment! is! necessary! to! identify! reasons! for! this! difference! and! potential! solutions.! Insufficient! guideline! implementation! may! lead! to! inadequate! performance! of! programmes.! The! focus! group! discussions! and! the! implementation! status! studies!identified!several!factors!related!to!implementation!of!guidelines.!
!
Factors!critical!for!failure!or!success!of!guideline!implementation! !
Availability!of!material!and!guidelines!
For! health! care! workers! as! users! of! guidelines,! the! nonPavailability! of! guidelines! and! material! hindered! effective!guideline!implementation!(chapters!5!and!6).!Not!all!TB!officers!and!health!care!facility!managers! had! guidelines! for! identification! and! diagnosis! of! (presumptive)! TB! patients.! Because! of! lack! of! material! such!as!N95!respirators!for!respiratory!protection,!health!care!workers!could!not!use!them.! The!availability!of!guidelines!is!the!result!of!the!dissemination!process!much!more!than!the!implementation! itself.!Absence!of!guidelines!at!the!health!care!facility!does!not!necessarily!mean!that!individual!health!care! workers!do!not!have!or!use!the!guidelines.!Dissemination!of!guidelines!in!subPSaharan!Africa!often!occurs! through!trainings!where!health!care!workers!receive!a!copy!of!the!guidelines!which!they!consider!this!their! personal!copy7.! NonPavailability!of!material!hindering!implementation!of!TB!infection!prevention!and!control!measures!is! reported! in! other! subPSahara! African! settings.8,9! This! applies! to! other! health! care! areas! as! well.! A! study!
evaluating! followPup! for! HIVPexposed! infants! found! that! health! care! system! challenges! such! as! irregular! availability! of! consumables! affected! improvement! of! followPup! for! these! children.10! NonPavailability! of!
Consistency!
Health! care! workers! found! it! difficult! to! apply! some! of! the! recommendations! of! guidelines! in! their! daily! practice.!This!was!related!to!recommendations!conflicting!with!other!recommendations!or!with!expected! professional! conduct! (chapter! 5);! to! limited! applicability! in! their! setting! (chapter! 2);! and! to! insufficient! clarity! of! the! recommendations! (chapters! 5,! 6! and! 7).! These! aspects! we! call! the! consistency! of! the! guidelines.!!
We! found! conflicting! recommendations! on! how! to! correctly! separate! coughing! patients.! The! recommendation!to!initiate!ART!in!HIVPinfected!TB!patients!depending!on!CD4+!cell!count!results!at!the! start!of!TB!treatment,12!was!difficult!to!apply!in!Mozambican!health!care!facilities!without!CD4+!cell!count!
equipment.!Lack!of!clarity!of!guidelines!existed!for!separation!of!(presumptive)!TB!patients,!for!the!use!of! N95! respirators! and! on! how! and! where! to! measure! airspeed! when! assessing! ventilation! using! a! vaneometer.!!
Consistency! of! guidelines! is! not! always! achieved.! A! study! in! South! Africa! evaluated! the! process! of! implementation! of! provider! initiated! HIV! testing! and! counselling! in! clinics! for! sexually! transmitted! infections!(STI).13!The!intervention!used!a!patientPcentred!counselling!style!that!did!not!align!easily!with!the!
communication!style!used!in!the!STI!clinics.!The!conflicting!styles!reduced!the!efficient!integration!of!the! new! intervention.! Health! care! workers! are! more! likely! to! use! guidelines! if! these! are! in! line! with! their! expected!professional!conduct.!!
The!TB!infection!prevention!and!control!guidelines!are!not!clear!on!how!to!assess!ventilation!in!health!care! facilities.14! The! framework! for! implementing! this! guideline! suggests! using! a! vaneometer! but! does! not!
provide!specific!instructions!on!measuring!the!air!velocity!in!terms!of!the!position!of!the!vaneometer!and! the! frequency! of! the! measurements.15! The! findings! from! our! study! on! assessing! ventilation! using! a!
vaneometer!suggest!that!clearer!instructions!for!measuring!air!velocity!are!possible!(chapter!7).!A!single! measurement! in! any! position! in! the! opening! is! sufficient.! However,! the! study! did! not! compare! the! vaneometer! method! with! other! methods! of! assessing! ventilation.! In! addition,! recommendations! on! air! changes!per!hour!for!natural!ventilation!do!not!exist.!Some!of!the!values!of!the!air!changes!per!hour!in! Mozambican!facilities!seem!quite!high!(more!than!100)!compared!to!the!level!for!adequate!ventilation!of! 12!air!changes!per!hour.!This!recommendation!is!for!mechanically!ventilated!highPrisk!areas,16!and!similar! recommendations!for!natural!ventilation!are!lacking.!! ! Role!of!patients! Recommendations!in!guidelines!target!mostly!receivers!of!care,!clients!or!patients!(hereafter!referred!to!as! patients).! Patients! have! their! own! values! or! limitations! that! may! result! in! them! making! a! decision! differently!from!the!professional!recommendations.17!Our!findings!showed!that!patients!followed!advice!on! cough!hygiene,!but!socioeconomic!factors!hindered!patients!to!follow!recommendation!on!receiving!daily! treatment!at!the!facility!(chapter!5).!A!study!in!Kenya!explored!attitudes!of!discordant!couples!to!early!ART! initiation!of!the!HIVPinfected!partner,!i.e.!initiating!ART!as!soon!as!HIVPinfection!is!diagnosed!irrespective!of! the!CD4+!cell!count,!as!recommended!by!the!WHO.18!The!study!found!that!participants!were!interested!in! early!ART!initiation!because!of!health!reasons!but!had!great!reservations!because!of!side!effects,!the!lifeP long!duration!of!the!therapy,!and!stigma.!In!addition!to!these,!they!perceived!ART!as!medication!for!the!last! stage!of!the!disease,!when!the!patient!“is!nearing!the!grave”.!These!personal!values!may!act!as!a!hindering! factor!more!than!the!health!reasons!are!facilitating!factors!for!following!the!recommendation.!
The!motivation!to!change!by!health!care!workers!
The!motivation!to!change!practice!is!crucial!for!the!implementation!of!guideline!recommendations.!In!the! focus!group!discussions!on!TB!infection!prevention!and!control!measures!this!was!clearly!elicited!from!the! participants! (chapter! 5).! The! earlier! mentioned! factors! availability! of! guidelines! and! material! and! the! consistency,!and!the!role!of!patients!influenced!health!care!workers’!motivation.!The!irregular!availability! of!N95!respirators!influenced!negatively!the!motivation!to!use!these!even!if!available.!Health!care!workers! were!not!clear!on!the!recommendations!on!separation!of!patients!resulting!in!them!feeling!confused!and! uncertain!in!their!actions.!Health!care!workers!were!content!with!the!correct!practice!of!cough!hygiene!as!a! result!of!their!health!education!activities.! Motivation!to!change!has!in!several!studies!been!recognised!as!a!major!factor!in!implementing!change.!A! study!from!Kenya!listed!difficulties!in!accepting!change!and!the!lack!of!motivation!among!the!barriers!for! implementing! guidelines.19! A! qualitative! study! from! Uganda! found! that! positive! approaches! such! as!
feedback!would!motivate!health!care!workers!more!than!negative!approaches!such!as!penalties.20!A!South!
African!study!on!implementation!of!TB!infection!prevention!and!control!practices!showed!that!motivation! and! behavioural! skills! were! associated! with! better! selfPreported! practice,! but! having! the! correct! information!was!not.21!!
!
We!identified!these!critical!factors!through!studies!in!Mozambique.!We!consider!the!findings!relevant!for! similar! settings! such! as! subPSaharan! Africa.! In! subPSaharan! Africa! TB! and! HIV! programmes! base! their! national!guidelines!on!the!WHO!guidelines.!The!national!disease!programmes!determine!the!activities!at! regional,!district!and!health!care!facility!level.!Other!studies!on!guideline!implementation!showed!similar! results.! An! evaluation! of! the! effect! of! guidelines! on! the! implementation! of! health! care! programmes! in! Uganda! showed! that! more! than! 60%! of! the! guidelines! developed! by! the! Ministry! of! Health! were! not! available!at!the!level!of!service!provision.22!A!study!evaluating!the!use!of!maternal!health!guidelines!found!
that!the!use!of!the!guidelines!in!practice!was!limited.7!The!study!suggested!presenting!the!guidelines!in!a!
different!format!to!increase!the!applicability.!In!Kenya!researchers!identified!limited!resources,!difficulties! to! accept! change,! lack! of! motivation,! and! conflicting! attitudes! and! beliefs! among! the! reasons! for! insufficient!implementation!of!guidelines.19!In!relation!to!infection!prevention!and!control!the!findings!are!
relevant! globally.! A! recent! systematic! review! revealed! availability! of! material! and! resources! and! appropriate!use!of!guidelines!among!the!factors!contributing!to!the!prevention!of!health!care!associated! infections.23!!
!
If!simple!tools!for!analysis!of!routine!data!as!described!in!the!first!part!of!this!chapter!would!be!available,! would!the!analysis!positively!influence!implementation!of!guidelines?!Table!12!provides!an!overview!of!the! possible! positive! influences! it! may! have! on! the! factors! that! we! identified! as! relevant! for! the! implementation.!!
Guideline!implementation!is!not!a!purpose!in!itself.!The!main!purpose!of!guidelines!is!to!improve!care.1!In!a!
review! of! 59! guideline! evaluations,! 55! improved! the! process! of! care.24! Though! only! 11! evaluations! also!
assessed!the!outcome!of!care,!which!improved!significantly!in!nine!of!them,!it!may!mean!that!evaluation!of! the!implementation!of!guidelines!is!a!good!proxy!for!improved!care.!It!is!possible!to!improve!care!through! routine!analysis!of!the!available!data.!An!evaluation!of!the!use!of!an!obstetric!audit!tool!showed!that!such! an!approach!does!improve!care.25!Every!two!to!three!weeks!the!staff!of!the!facility!met!to!discuss!preP!
!
Table!12.!Possible!positive!influences!of!local!analysis!and!evaluation!feeding!into!guideline!development!
!
selected! cases! of! maternal! deaths! or! severe! pregnancy! related! complications.! If! the! audit! revealed! that! substandard! care! caused! or! contributed! to! the! death! or! complication,! the! meeting! would! come! up! with! recommendations! such! as! refresher! training! or! increased! supervision! on! the! ward.! The! effect! of! these! recommendations!was!reported!back!to!the!audit!meeting.!A!qualitative!study!on!the!perceptions!of!health! care!workers!of!the!obstetric!audit!and!its!feedback!found!that!health!care!workers!valued!the!tool!as!a! mechanism! to! improve! care.26! The! health! care! workers! also! appreciated! the! meetings! as! a! learning!
opportunity.! Learning! serves! as! a! motivator! for! health! care! workers,11! and! as! such! the! use! of! routinely!
available!data!may!increase!health!care!worker!motivation!to!change.!
Improved! implementation! of! guidelines! evaluated! in! this! thesis! could! result! in! a! lower! risk! for! TB! transmission!for!health!care!workers,!patients!and!visitors!of!health!care!facilities;!in!reduced!morbidity!and! mortality!due!to!smearPnegative!and!extrapulmonary!TB;27!and!in!reduced!mortality!among!HIVPinfected!TB! patients!because!of!timely!initiation!of!ART!in!HIVPinfected!TB!patients.28! ! Implications!for!guideline!implementation! When!implementing!guidelines,!implementers!need!to!take!into!consideration!the!availability!of!guidelines! and! the! necessary! material,! the! consistency! of! the! guidelines,! the! possible! role! of! patients! and! the! motivation!of!health!care!workers!to!change!their!practice.!Especially!for!the!consistency!of!the!guideline! and!the!role!of!the!patients!it!would!be!helpful!to!take!these!into!account!during!the!development!of!the! guideline.!Checking!guidelines!with!other!guidelines!on!the!disease!or!care!process!can!identify!and!prevent! inconsistencies!between!guidelines.!If!recommendations!are!not!applicable!in!some!settings!or!situations,! alternatives!could!guide!health!care!workers!in!their!actions.!If!certain!values!or!attitudes!of!patients!on!the! recommendations! in! a! guideline! were! known,! this! knowledge! would! influence! the! implementation! strategy.!The!implementation!strategy!is!key!in!successful!implementation!of!guidelines.29!
Factor! Influence!
Availability! of! guidelines! and! the! necessary! material.!
The! analysis! itself! would! not! influence! availability,! but! may!identify!nonPavailability.!
Consistency!
Identification! of! inconsistencies! with! other! guidelines,!
expected! professional! conduct! and! unclear!
recommendations;! suggestions! on! how! to! overcome! these.!
The!role!of!patients!
Health!care!workers!interacting!with!patients!may!know! what! is! acceptable! to! patients;! if! not! they! are! in! a! position!to!ask!patients!what!is!acceptable!to!them.!
The!motivation!to!change!by!guideline!users!
Through! taking! into! account! health! care! workers’! concerns! and! suggestions,! the! motivation! to! change! increases.!
Remaining!challenges!and!implications!for!further!research!
Operational!research,!sometimes!called!implementation!research,!as!defined!by!Harries!et!al.!as!“research! into!strategies,!interventions,!tools!or!knowledge!that!can!enhance!the!quality,!coverage,!effectiveness!or! performance!of!the!health!system!or!programmes!in!which!the!research!is!being!conducted”,!considers!this! research! part! of! routine! monitoring! and! evaluation.30! Future! research! should! develop! and! evaluate!
pragmatic!tools!for!systematic!use!of!these!tools!as!part!of!the!routine!monitoring!and!evaluation!activities.! These!studies!should!assess!whether!the!use!of!these!tools!facilitates!the!evaluation!process!and!improves! care.!Because!of!different!issues!and!questions!at!different!levels!in!the!health!care!system,!the!tools!need! to! be! flexible! and! easy! adaptable! to! address! these! various! issues! and! questions.! A! recently! published! pragmatic!method!of!monitoring!and!evaluating!TB!case!finding!interventions!using!routine!TB!notification! data!in!addition!to!data!related!to!the!specific!intervention,!provides!a!good!example!of!how!this!can!be! done.31! The!challenge!of!the!guideline!implementation!process!is!that!it!is!influenced!by!various!factors,!each!of! which!on!their!own!would!probably!not!increase!implementation!of!the!guidelines.!The!availability!of!N95! respirators!would!not!have!solved!the!fact!that!health!care!workers!were!not!clear!on!how!and!when!to!use! these!and!how!to!maintain!these!inPbetween!use.!Had!health!care!workers!been!perfectly!clear!on!how!to! separate! patients,! they! may! have! encountered! challenges! from! the! patients! considering! separation! embarrassing.32!Motivation!of!health!care!workers!is!a!challenge!is!many!resourcePlimited!settings,11!and!
probably!affects!willingness!to!change.!Further!studies!should!assess!what!is!the!most!effective!method!to! address!these!factors!and!the!effect!on!programme!performance.!
There! is! need! to! investigate! which! method! is! best! to! assess! ventilation! and! under! which! conditions.! In! addition,! we! need! evaluation! whether! the! recommendations! for! air! changes! per! hour! for! mechanical! ventilation!hold!for!natural!ventilation.!
!
Conclusion!!
This! thesis! identified! several! factors! that! influence! guideline! implementation.! Evaluation! of! guideline! implementation!using!routine!data!is!a!simple!way!to!identify!where!implementation!may!be!insufficient.! Programmes!should!build!such!evaluations!into!their!routine!monitoring!and!evaluation!systems!as!part!of! a!continuous!effort!to!improve!programme!performance.!
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