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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1. General+introduction+
!
Tuberculosis! (TB)! and! Human! Immunodeficiency! virus! (HIV)! infections! remain! considerable! public! health! challenges!for!many!countries.!Worldwide,!the!number!of!new!HIV!infections!is!declining.1!This!also!applies!
to!subHSaharan!Africa!though!in!2012!still!70%!of!the!world’s!new!infections!occurred!in!this!region.!Of!all! new! infections! in! subHSaharan! Africa,! almost! 50%! occur! in! Southern! Africa.! In! Mozambique! alone,! an! estimated!120,000!new!HIV!infections!occurred!in!2012.!
For!TB,!twentyHtwo!high!burden!countries!represent!80%!of!the!world’s!TB!cases.2!In!terms!of!estimated!
incidence! and! prevalence,! Southern! Africa! bears! the! heaviest! TB! burden:! of! the! five! countries! with! the! highest!estimated!TB!incidence,!four!are!in!Southern!Africa.!According!to!the!2014!Global!TB!report,!the! incidence!ranges!from!552!per!100,000!population!in!Mozambique!and!Zimbabwe!to!1,382!in!Swaziland.2! HIV!is!one!of!the!strongest!risk!factors!for!developing!TB!and!has!been!the!driving!force!for!the!TB!incidence! in!the!region.3! The!Directly!Observed!Treatment,!Short!course!(DOTS)!strategy!has!guided!global!TB!control!efforts!since! 1993.4!The!strategy!consist!of!several!pillars!including!short!course!chemotherapy,!direct!observation!of!the! intake!of!the!medication!during!the!first!two!months,!notification!and!evaluation!of!reported!patients,!and! ensuring!the!availability!of!medicines!at!all!times.!It!became!part!of!the!Stop!TB!Strategy!in!2006,!which!also! included!components!to!address!the!TB/HIV!challenge.5!Policies!and!guidelines!describe!in!more!detail!the!
interventions! and! activities! to! carry! out! the! strategy.! The! purpose! of! guidelines! in! general! is! to! improve! patient!care!and!assist!in!medical!decisionHmaking.6!Since!2009,!the!World!Health!Organization!(WHO)!uses!
an!elaborate!guideline!development!process,!which!includes!a!systematic!review!of!the!available!evidence! and! an! assessment! of! the! quality! of! that! evidence.7! The! review! and! quality! assessment! result! in!
recommendations.!To!finalize!the!formal!guideline!process,!there!is!a!need!to!disseminate,!implement!and! evaluate!these!recommendations.!! Most!countries’!strategic!TB!plans!to!guide!TB!control!at!country!level!reflect!the!Stop!TB!Strategy.!The!TB! national!strategic!plan!2008H2012!for!Mozambique!included!most!of!its!elements.8!TB!manuals!of!countries! present!the!translation!and!adaptation!of!these!global!strategies!and!guidelines!to!the!local!setting.!It!is! mainly!these!TB!manuals!that!guide!the!implementation!and!use!of!TB!control!interventions!at!the!various! levels!of!the!health!care!system.!! The!translation!of!international!policy!and!guidelines!into!national!practice!constitutes!a!major!challenge.9! Reasons!may!be!that!relevant!factors!for!effective!guideline!production!as!described!by!Thomson!et!al!are! not!taken!into!account.6!These!relevant!factors!are:!the!development!group,!the!development!itself!and!the! presentation!of!the!guidelines,!dissemination,!implementation!and!evaluation.!! ! Guideline+development+group+ The!development!of!guidelines!is!usually!a!team!effort.!Key!affected!groups,!including!representatives!from! users,!should!participate!in!the!development!process.10!The!team!should!have!the!necessary!skills,!such!as!
scientific! and! group! leadership,! to! develop! the! guideline.6! The! team! composition! may! influence!
implementation! and! adherence! to! the! guidelines.! A! study! evaluating! adherence! to! TB! contact! tracing! guidelines,! concluded! that! representation! of! the! endHusers! in! the! guideline! development! process! could! improve!adherence!to!these!guidelines.11!
Guideline+development+and+presentation+
The! WHO! handbook! for! guidelines! development! prescribes! a! format! for! WHO! guidelines:! an! executive! summary,! a! main! body! and! appendices.7! The! handbook! recommends! 1,! 3! and! 25! pages! respectively! as!
lengths!for!these!sections.!Thomson!et!al!suggest!that!the!proposed!use!determines!the!guideline!format.6!
A!study!in!Uganda!evaluated!how!factors!related!to!the!guideline!development!process!influenced!health! care!service!delivery.12!Presentation!of!the!evaluated!guidelines!was!mostly!in!the!form!of!booklets,!even!
though! staff! at! the! service! delivery! level! often! preferred! charts! because! of! the! easy! language! and! illustrative!diagrams.!!
!
Dissemination+
Dissemination! of! guidelines! means! making! the! guidelines! available! to! those! that! should! use! them.! This! implies! that! the! intended! users! are! clear.! In! the! Uganda! study,! many! guidelines! were! for! health! care! workers!without!specifying!the!level!and!the!qualification!of!these!workers.12!Also,!dissemination!did!not! occur!systematically!to!all!relevant!levels.!Dissemination!approaches!include!through!professional!bodies,! continuing!medical!education!efforts,!and!relevant!journals!13.!The!most!common!approach!in!subHSaharan! Africa!is!training!of!health!care!workers.!Health!care!workers!attend!workshops!where!they!receive!a!copy! of!the!guidelines14!which!they!perceive!as!their!personal!copies.!This!limits!availability!to!other!health!care! workers!and!at!the!facility!if!the!health!care!worker!transfers!to!another!facility.! ! Implementation+
Implementation! often! involves! a! change! in! practice! which! could! be! achieved! through! addressing! the! knowledge,!attitudes!and!practices!of!the!professionals!involved.6!This!may!not!be!sufficient.!A!variety!of!
organisational! aspects! such! as! revision! of! professional! roles,! multidisciplinary! teams,! integrated! care,! knowledge! and! quality! management! contribute! to! achieve! the! desired! change.15! Shifting! tasks! from!
medical! doctors! to! nonHdoctor! clinicians! is! an! example! of! the! revision! of! professional! roles.! Due! to! the! shortage!of!medical!doctors,!Mozambique!evaluated!the!quality!of!care!of!nonHdoctor!clinicians!for!HIVH infected! patients.16! The! nonHdoctor! clinicians! received! a! 14Hday! training! course! on! care! for! HIVHinfected!
patients.! The! study! found! that! in! most! clinical! encounters! with! patients! they! did! not! adhere! to! the! guidelines!as!taught!in!the!course.!!
Another! example! where! the! organisation! of! an! intervention! did! not! lead! to! the! desired! improvements! comes!from!Malawi!in!the!early!days!of!TB/HIV!collaboration.!Initiation!of!antiretroviral!therapy!(ART)!in!coH infected!TB!patients!was!postponed!until!they!completed!two!months!of!TB!treatment.17!This!resulted!in!
more!difficulties!to!achieve!the!required!change!in!practice,!which!was!the!provision!of!ART.!The!reason! was!that!most!patients!had!returned!to!their!communities!where!few!if!any!HIV!treatment!services!were! available.!After!returning!to!their!communities!and!feeling!better!on!TB!treatment,!patients!were!less!likely! to! return! to! the! hospital! for! ART.! Had! initiation! of! ART! been! integrated! in! the! first! two! months! of! TB! treatment! while! the! patients! still! attended! the! hospital! and! felt! more! ill,! ART! coverage! may! have! been! higher.!!
Other! factors! relevant! for! implementation! are! support! and! leadership,! and! alignment! with! existing! roles! and! tasks.18! Despite! the! embracing! of! operational! or! implementation! research,! there! seems! to! be!
inadequate!attention!for!implementation.19!
Evaluation++
Newly!emerging!evidence!necessitates!the!revision!of!guidelines!periodically.!The!guideline!development! process!includes!evaluation!that!should!also!inform!the!revision!of!the!guidelines.6!This!does!not!seem!to!
happen! systematically,! nor! is! it! clear! who! should! do! the! evaluation! and! how.! The! WHO! handbook! for! guideline!development!includes!only!half!a!page!on!evaluation!and!monitoring!compared!to!7!pages!on!the! assessment! of! the! evidence.7! The! half! page! provides! very! little! practical! information! on! carrying! out! an!
evaluation.!!
Recommendations! made! in! guidelines! should! have! an! effect! or! outcome.7! Therefore! guidelines! should! include! measurable! indicators! to! monitor! the! outcome! of! the! guideline.! However,! measuring! outcomes! alone!is!not!sufficient!and!it!is!necessary!to!take!into!account!all!parts!of!the!development!process.6!If!the! dissemination!process!occurred!inadequately,!one!would!not!expect!improved!outcomes.!To!interpret!the! outcome!indicators,!baseline!information!or!a!reference!value!for!the!indicator!is!needed.! + Research+questions+ + The!overall!objective!of!this!thesis!is!to!assess!how!guideline!implementation!and!evaluation!contribute!to! health! care! decisionHmaking! and! to! assess! what! critical! factors! contribute! to! successful! or! unsuccessful! implementation! of! TB! control! guidelines! through! case! studies! mainly! conducted! in! Mozambique.! We! specifically! evaluate! two! components! of! the! guideline! development! process! as! outlined! above,! i.e.! implementing!guidelines!and!evaluation!of!guidelines.!
The!central!research!questions!of!this!thesis!are:!
1. How! can! assessment! of! guideline! implementation! and! its! evaluation! contribute! to! health! care! decisionHmaking?! Guidelines!support!health!care!decisionHmaking!at!both!patient!and!health!care!service!delivery!level.!To!do! so!effectively,!health!care!workers!and!decisionHmakers!should!use!guidelines!and!monitor!their!outcomes.! If!this!occurs!either!not!or!incompletely,!the!decisionHmaking!process!lacks!crucial!information.!This!could! lead!to!poor!or!no!decisionHmaking.!In!this!thesis!we!evaluate!outcomes!described!in!guidelines!with!the! aim!to!inform!health!care!decisionHmaking.! 2. Which!factors!are!critical!for!failure!or!success!in!guideline!implementation?!
Improved! health! care! is! one! of! the! objectives! of! guidelines,! however,! implementation! of! these! is! often! challenging.!If!the!desired!outcomes!of!guidelines!are!not!achieved,!assessment!of!the!reasons!for!this!need! exploration.!It!seems!logical!to!evaluate!guideline!implementation!or!the!guideline!itself,!though!this!does! not!happen!systematically.!In!this!thesis!we!assess!various!aspects!of!guideline!implementation!to!identify! factors!that!contribute!to!failure!and!success!of!the!implementation.! ! Guidelines+assessed+ +
To! address! these! questions,! the! thesis! focuses! on! guideline! implementation! and! evaluation! in! a! local! context.!It!looks!at!several!guidelines!developed!in!the!first!decade!of!the!21st!century!when!it!became!clear!
that!the!prevailing!strategy!for!TB!control,!the!DOTS!strategy,!was!insufficient!in!the!context!of!HIV.20!The!
willingness! to! provide! care! to! HIVHinfected! individuals! together! with! availability! of! funding! created! opportunities!that!did!not!exist!before.!!
Studies! had! found! that! many! HIVHinfected! patients! died! of! TB! and! that! provision! of! coHtrimoxazole! preventive!therapy!reduced!the!mortality!for!coHinfected!TB!patients.22!Other!studies!identified!TB!clinics!as!
a!good!entry!point!for!testing!for!and!diagnosing!HIV!infection.23!Centres!for!voluntary!HIV!testing!proved!
good!places!to!screen!for!TB.24!Isoniazid!preventive!therapy!proved!to!protect!HIVHinfected!individuals!from!
TB!although!the!effect!was!limited!to!a!few!years.25!!
HIV! and! multiHdrug! resistant! TB! (MDRHTB)! placed! infection! control! back! on! the! agenda.26! HIVHinfected!
people!have!a!vulnerability!to!develop!TB!disease!soon!after!they!acquire!infection!with!HIV.27!MDRHTB!has!
poorer!treatment!outcomes!compared!to!drugHsensitive!TB,!and!is!much!more!costly!to!treat.!An!outbreak! of!MDRH!and!extensively!drug!resistant!(XDR)!TB!in!South!Africa!identified!nosocomial!transmission!as!the! most! important! cause! for! the! outbreak! that! had! a! high! mortality! in! the! mainly! HIVHinfected! patients.28!
Mozambique!has!the!combined!challenge!of!an!high!HIV!prevalence29!and!a!relatively!high!percentage!of!
new!TB!patients!having!MDRHTB!(3.5%).30!MDRHTB!is!more!frequent!in!HIVHinfected!people.30,31!
Several! of! these! developments! contributed! to! the! development! of! the! interim! policy! for! TB/HIV! collaborative!activities!in!2004.32!The!policy!recommends!sets!of!activities!for!collaboration!in!health!care!
facilities!to!decrease!the!burden!of!TB!in!people!living!with!HIV!(PLHIV),!and!to!decrease!the!burden!of!HIV! in!TB!patients.!Intensified!case!finding,!the!provision!of!isoniazid!preventive!therapy!and!infection!control!in! health!care!and!congregate!settings!are!the!activities!to!decrease!the!burden!of!TB!in!PLHIV.!HIV!testing! and! counselling,! HIV! prevention! methods,! coHtrimoxazole! preventive! therapy,! HIV! care! and! support,! and! provision!of!antiHretroviral!therapy!(ART)!are!the!activities!to!reduce!to!burden!of!HIV!in!TB!patients.!! The!WHO!also!published!guidelines!on!the!diagnosis!of!smearHnegative!and!extrapulmonary!TB,33!and!on!
infection!control!in!health!care!facilities.34!SmearHnegative!and!extrapulmonary!TB!occur!more!frequently!in!
HIVHinfected! people! and! are! a! diagnostic! challenge! in! settings! depending! mainly! on! smear! microscopy.35!!!
Several!studies!found!substantially!higher!notification!rates!of!TB!among!health!care!workers!in!comparison! with!the!general!population.!Nursing!students!in!Zimbabwe!had!a!much!higher!prevalence!of!TB!infection! compared!to!polytechnic!school!students.36!Hospital!staff!in!Kenya!had!high!TB!notification!rates!and!the!
risk! for! TB! disease! was! higher! for! staff! members! that! spend! more! hours! with! patients.37! These! studies!
illustrated!clearly!that!infection!control!needs!strengthening.! !
Research+setting++ +
The! studies! of! this! thesis! took! place! in! Mozambique.! The! country! notified! an! increasing! number! of! TB! patients!since!1990!and!reached!almost!50,000!cases!in!2012!(Figure!1).38!The!estimated!incidence!in!2011!
of! 551! per! 100,000! would! result! in! almost! 139,000! cases,! suggesting! that! many! TB! cases! remain! undiagnosed.38!!
Mozambique! also! faces! a! substantial! HIV! epidemic.! A! national! population! prevalence! survey! in! 2009! showed! that! nationwide! 11.5%! of! the! adult! population! was! infected! with! HIV.29! Prevalence! within! the!
country! showed! a! large! variation! from! 3.7%! in! Niassa! province! to! 25.1%! in! Gaza! province.! Furthermore,! prevalence!was!higher!in!women!compared!to!men,!and!in!urban!areas!compared!to!rural!areas.!Many!TB! patients! in! Mozambique! are! coHinfected! with! HIV:! in! 2013,! 91%! of! notified! TB! patients! knew! their! HIVH! status!and!56%!were!HIV!positive.2!
!
Figure'1'Incident'TB'notifications'in'Mozambique'1990;2012'
!
Mozambique!became!independent!from!Portugal!in!1975.!Soon!thereafter!the!country!entered!into!a!civil! war! that! lasted! until! the! Peace! Agreement! in! 1992.39! Conflict! situations! contribute! to! (re)! emergence! of!
infectious! diseases! through! various! mechanisms.40! Conflict! situations! may! lead! to! a! breakdown! of! the!
health! care! infrastructure! including! disruption! of! disease! control! programmes! and! reduced! practice! of! infection! control.! It! also! leads! to! inadequate! disease! surveillance! and! increased! movement! of! the! population.!Access!of!the!population!to!health!care!services!and!of!the!health!care!services!to!reach!out!to! the!population!for!interventions!may!be!reduced.!In!the!prolonged!civil!war,!many!of!these!mechanisms! also!affected!Mozambique’s!infrastructure.!Roads,!schools!and!health!care!facilities!were!destructed!and! became!dysfunctional.41!
The! National! TB! Control! Programme! (Programa' Nacional' de' Controlo' de' TB)! has! directed! TB! control! in! Mozambique! since! the! 1980s.! Mozambique! practised! the! DOTS! strategy! already! before! it! became! the! global!policy9!because!of!the!international!support!advising!implementation!of!short!course!chemotherapy,!
direct!observation!of!the!intake!of!the!medication!during!the!first!two!months,!evaluation,!notification!and! ensuring!availability!of!medicines.42!The!country!succeeded!full!implementation!of!the!strategy!only!in!2000!
because!the!war!limited!geographical!expansion.!
Mozambique! adopted! the! interim! policy! for! TB/HIV! collaborative! activities32,! the! guidelines! on! the!
diagnosis! of! smearHnegative! and! extrapulmonary! TB33! and! on! infection! control! in! health! care! facilities34!
mainly!through!translation!into!Portuguese.!Routine!supervisory!visits!to!districts!and!health!care!facilities! in!Mozambique!identified!several!gaps!and!challenges!related!to!the!use!of!these!guidelines.!Health!care! workers!in!health!care!facilities!and!at!district!level!did!not!always!know!how!to!use!the!guidelines.!There! was!no!system!in!place!to!assess!their!implementation.!Although!health!care!facilities!and!districts!collect!a! substantial! amount! of! data! on! a! monthly! or! quarterly! basis,! they! did! not! use! the! data! to! evaluate! their! performance.! Also,! countries! including! Mozambique! spend! a! substantial! amount! of! resources! on! the! process! of! guideline! development! and! implementation.! Therefore! an! evaluation! of! guideline! implementation!at!health!care!facility!and!district!level!seemed!warranted.!! 0! 10000! 20000! 30000! 40000! 50000! 60000! 1990! 1991! 1992! 1993! 1994! 1995! 1996! 1997! 1998! 1999! 2000! 2001! 2002! 2003! 2004! 2005! 2006! 2007! 2008! 2009! 2010! 2011! 2012!
The!studies!took!place!in!three!provinces!in!central!Mozambique:!Manica,!Sofala!and!Tete!(Figure!2).!!
!
! Legend:!! Sm+!=!smearFpositive!pulmonary!tuberculosis! AF!=!all!forms!of!tuberculosis! TB!data!concern!number!of!notifications!of!the!year!2007!and!are!from!the!national!TB!control!programme.!The!population!data!come!from!the! same!source.!!
Figure'2'The'three'provinces'of'Mozambique'where'the'research'took'place' ! At!the!start!of!the!studies!in!2007,!these!three!provinces!had!a!population!of!4.7!million,!representing!23%! of!the!country’s!population.!They!notified!4,399!sputum!smearFpositive!TB!cases!and!9,399!all!forms!of!TB! cases!(National!TB!Programme!data).!This!was!24!and!25%!of!the!country’s!total!notification,!respectively.! The!HIV!prevalence!in!the!provinces!was!15.3%!in!Manica,!15.5%!in!Sofala!and!7%!in!Tete!Province.29!The! Ministry! of! Health! provides! guidelines! for! TB! and! HIV! control! activities! in! the! country! through! the! National! TB! Programme! and! the! National! Aids! Control! Programme! (Programa' Nacional' de' Controlo' das'
ITS/HIV/SIDA).! The! National! TB! Programme! and! the! National! Aids! Control! Programme! distribute! the!
guidelines!through!the!provincial!and!district!health!offices!to!the!health!care!facilities.!Supervision!occurs! from!one!level!to!the!next.!Data!flow!moves!the!other!direction:!from!health!care!facilities!to!the!district! that!prepares!an!aggregated!report!for!the!province.!Similarly,!the!provinces!prepare!an!aggregated!report! for!the!national!level.!Review!meetings!take!place!at!the!various!levels!to!discuss!progress.!! All!districts!keep!a!TB!register!with!nominal!TB!notifications.!Larger!health!care!facilities!also!maintain!a!TB! register,!but!smaller!ones!do!report!the!TB!notifications!to!the!district!where!these!enter!into!the!district! register.! !
Specific'research'questions' ' In!order!to!answer!the!central!research!questions!of!1)!How!can!assessment!of!guideline!implementation! and!its!evaluation!contribute!to!health!care!decision<making?!and!2)!Which!factors!are!critical!for!failure!or! success!in!guideline!implementation?,!we!formulated!specific!research!questions.!! The!specific!research!questions!are:!
1. How! can! routinely! available! TB! and! HIV! programme! data! facilitate! evaluation! of! guideline! implementation!and!assist!in!decision<making?!
The!evaluation!of!the!guideline!on!ART!use!in!chapter!2!investigates!whether! the!TB!programme!misses! opportunities! for! ART! initiation! because! of! non<availability! of! laboratory! results.! In! chapter! 3! we! assess! whether!routinely!available!data!are!a!good!source!for!evaluating!implementation!of!the!use!of!ART!in!co< infected! TB! patients! using! completeness! and! correctness! of! data! as! the! outcome! measure.! Chapter! 4! evaluates!the!possibility!to!assess!potential!under<diagnosis!of!some!forms!of!tuberculosis!with!routinely! available!data!on!TB!cases!and!HIV!prevalence.! 2. What!can!we!learn!from!users!about!the!implementation!of!guidelines?! Chapter!5!describes!how!health!care!workers!use!the!guideline!on!TB!infection!prevention!and!control.!We! evaluate!how!they!use!the!measures!as!outlined!in!this!guideline!to!reduce!their!occupational!TB!infection! risk.!Furthermore,!it!describes!the!challenges!health!care!workers!face!in!their!work!practice!while!using! these!guidelines.!! 3. What!is!the!implementation!status!of!current!tuberculosis!guidelines!in!Mozambique?!
In! chapter! 6! we! evaluate! the! level! of! implementation! of! selected! TB! infection! prevention! and! control! measures! in! health! care! facilities.! In! chapter! 7! we! assess! a! specific! part! of! the! guideline! on! TB! infection! prevention!and!control:!the!assessment!of!ventilation!in!rooms!in!health!care!facilities.!We!assess!how!to! conduct!measurement!of!air!velocity,!an!essential!component!in!ventilation!assessment.!!
! !
References'
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