Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method study
Background: Despite the availability of free drug-resistant tuberculosis (DR-TB) care in Nigeria since 2011, the country continues to tackle low case notification and treatment rates. In 2018, 11% of an estimated 21,000 cases were diagnosed and 9% placed on treatment. These low rates are nevertheles...
| Main Authors: | , , , , , |
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| Format: | Article |
| Language: | English |
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Elsevier
2020-12-01
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| Series: | Journal of Clinical Tuberculosis and Other Mycobacterial Diseases |
| Subjects: | |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S2405579420300577 |
| _version_ | 1819061424423436288 |
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| author | Charity Oga-Omenka Jody Boffa Joseph Kuye Patrick Dakum Dick Menzies Christina Zarowsky |
| author_facet | Charity Oga-Omenka Jody Boffa Joseph Kuye Patrick Dakum Dick Menzies Christina Zarowsky |
| author_sort | Charity Oga-Omenka |
| collection | DOAJ |
| description | Background: Despite the availability of free drug-resistant tuberculosis (DR-TB) care in Nigeria since 2011, the country continues to tackle low case notification and treatment rates. In 2018, 11% of an estimated 21,000 cases were diagnosed and 9% placed on treatment. These low rates are nevertheless a marked improvement from 2015 when only 3.4% were diagnosed and 2.3% placed on treatment of an estimated 29,000 cases. This study describes the Nigerian DR-TB care cascade from 2013 to 2017 and considers factors influencing gaps in care. Methods: Our study utilized a mixed-method design. For the quantitative component, we utilized the national diagnosis and treatment databases, as well as the World Health Organization’s estimates for prevalence to construct a 5-year care cascade: numbers of patients at each level of DR-TB care, including incident cases, individuals who accessed testing, were diagnosed, initiated treated and completed treatment in Nigeria between 2013 and 2017. Using retrospective data for patients diagnosed in 2015, we performed the Fisher’s exact test to determine the association between patient (age and gender) and provider/patient (region- north or south) variables, permitting a closer look at the gaps in care revealed across the 5 years. Barriers to care were explored using framework thematic analysis of 57 qualitative interviews and focus group discussions with patients, including 5 cases not initiated on treatment from the 2015 cohort, treatment supporters, community members, healthcare workers and program managers in 2017. Results: A 5-year analysis of cascade of care data shows significant, but inadequate, increases in overall numbers of cases accessing care. On average, between 2013 and 2017, 80% of estimated cases did not access testing; 75% of those who tested were not diagnosed; 36% of those diagnosed were not initiated on treatment and 23% of these did not finish treatment. In 2015, children and patients in Northern Nigeria had odds of 0.3 [95% CI 0.1–0.7] and 0.4 [0.3–0.5] of completing treatment once diagnosed; while males were shown to have a 1.34 [95% CI 1.0–1.7] times greater chance of completing treatment after diagnosis. The main themes from qualitative data identified barriers to care along the care cascade at individual, family and community, as well as health systems levels. At the individual level, a lack of awareness of the true cause of disease and the availability of ‘free’ care was a recurring theme. Family interference was found to be a particular challenge for children and women. At the health system level, low index of suspicion, lack of rapid diagnostic tools and human resource shortages appeared to limit patients’ access. Conclusions: Any gains in diagnostic technology and shorter regimens are lost with inadequate access to DR-TB services. The biggest losses in the Nigerian cascade happen before treatment initiation. There is a need for urgent action on identified gaps in the DR-TB cascade in order to improve care continuity at multiple stages, improve health service delivery and facilitate TB control in Nigeria. |
| first_indexed | 2024-12-21T14:42:40Z |
| format | Article |
| id | doaj.art-e109b2ac8d5148dbb5e4e7ab89531579 |
| institution | Directory Open Access Journal |
| issn | 2405-5794 |
| language | English |
| last_indexed | 2024-12-21T14:42:40Z |
| publishDate | 2020-12-01 |
| publisher | Elsevier |
| record_format | Article |
| series | Journal of Clinical Tuberculosis and Other Mycobacterial Diseases |
| spelling | doaj.art-e109b2ac8d5148dbb5e4e7ab895315792022-12-21T19:00:07ZengElsevierJournal of Clinical Tuberculosis and Other Mycobacterial Diseases2405-57942020-12-0121100193Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method studyCharity Oga-Omenka0Jody Boffa1Joseph Kuye2Patrick Dakum3Dick Menzies4Christina Zarowsky5The School of Public Health of the University of Montreal (ÉSPUM), Montreal, Quebec, Canada; Centre de recherche en santé publique, Université de Montréal (CReSP), Canada; McGill University International TB Centre, Montreal, Quebec, Canada; Corresponding author at: 7101, Parc avenue, 3rd floor, Montreal, Quebec H3N 1X9, Canada.Dahdaleh Institute for Global Health, York Univeristy, Toronto, Canada; Centre for Rural Health, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South AfricaNational Tuberculosis and Leprosy Control Program, Abuja, NigeriaInstitute of Human Virology, Nigeria; University of Maryland School of Medicine, Baltimore, MD, USAMcGill University International TB Centre, Montreal, Quebec, Canada; Department of Epidemiology and Biostatistics, McGill University, Montreal, CanadaThe School of Public Health of the University of Montreal (ÉSPUM), Montreal, Quebec, Canada; Centre de recherche en santé publique, Université de Montréal (CReSP), Canada; School of Public Health, University of the Western Cape, South AfricaBackground: Despite the availability of free drug-resistant tuberculosis (DR-TB) care in Nigeria since 2011, the country continues to tackle low case notification and treatment rates. In 2018, 11% of an estimated 21,000 cases were diagnosed and 9% placed on treatment. These low rates are nevertheless a marked improvement from 2015 when only 3.4% were diagnosed and 2.3% placed on treatment of an estimated 29,000 cases. This study describes the Nigerian DR-TB care cascade from 2013 to 2017 and considers factors influencing gaps in care. Methods: Our study utilized a mixed-method design. For the quantitative component, we utilized the national diagnosis and treatment databases, as well as the World Health Organization’s estimates for prevalence to construct a 5-year care cascade: numbers of patients at each level of DR-TB care, including incident cases, individuals who accessed testing, were diagnosed, initiated treated and completed treatment in Nigeria between 2013 and 2017. Using retrospective data for patients diagnosed in 2015, we performed the Fisher’s exact test to determine the association between patient (age and gender) and provider/patient (region- north or south) variables, permitting a closer look at the gaps in care revealed across the 5 years. Barriers to care were explored using framework thematic analysis of 57 qualitative interviews and focus group discussions with patients, including 5 cases not initiated on treatment from the 2015 cohort, treatment supporters, community members, healthcare workers and program managers in 2017. Results: A 5-year analysis of cascade of care data shows significant, but inadequate, increases in overall numbers of cases accessing care. On average, between 2013 and 2017, 80% of estimated cases did not access testing; 75% of those who tested were not diagnosed; 36% of those diagnosed were not initiated on treatment and 23% of these did not finish treatment. In 2015, children and patients in Northern Nigeria had odds of 0.3 [95% CI 0.1–0.7] and 0.4 [0.3–0.5] of completing treatment once diagnosed; while males were shown to have a 1.34 [95% CI 1.0–1.7] times greater chance of completing treatment after diagnosis. The main themes from qualitative data identified barriers to care along the care cascade at individual, family and community, as well as health systems levels. At the individual level, a lack of awareness of the true cause of disease and the availability of ‘free’ care was a recurring theme. Family interference was found to be a particular challenge for children and women. At the health system level, low index of suspicion, lack of rapid diagnostic tools and human resource shortages appeared to limit patients’ access. Conclusions: Any gains in diagnostic technology and shorter regimens are lost with inadequate access to DR-TB services. The biggest losses in the Nigerian cascade happen before treatment initiation. There is a need for urgent action on identified gaps in the DR-TB cascade in order to improve care continuity at multiple stages, improve health service delivery and facilitate TB control in Nigeria.http://www.sciencedirect.com/science/article/pii/S2405579420300577TB Care CascadeNigeriaAccess to healthcareDrug-resistant tuberculosisMixed-methodsDiagnosis and treatment |
| spellingShingle | Charity Oga-Omenka Jody Boffa Joseph Kuye Patrick Dakum Dick Menzies Christina Zarowsky Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method study Journal of Clinical Tuberculosis and Other Mycobacterial Diseases TB Care Cascade Nigeria Access to healthcare Drug-resistant tuberculosis Mixed-methods Diagnosis and treatment |
| title | Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method study |
| title_full | Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method study |
| title_fullStr | Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method study |
| title_full_unstemmed | Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method study |
| title_short | Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method study |
| title_sort | understanding the gaps in dr tb care cascade in nigeria a sequential mixed method study |
| topic | TB Care Cascade Nigeria Access to healthcare Drug-resistant tuberculosis Mixed-methods Diagnosis and treatment |
| url | http://www.sciencedirect.com/science/article/pii/S2405579420300577 |
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