Background
Methods
Setting
TB literacy and treatment counselling intervention
Purpose | Description of methods |
---|---|
Refine intervention framework and counseling training | Quantitative: None Qualitative: We invited clinic staff involved in TB/HIV care to a focus group discussion (FGD) to discuss the barriers to retention in TB care and to obtain their feedback on the intervention. The FGD was facilitated by a trained study team member (BS) in English and isiZulu and followed a semi-structured, open-ended interview guide. We thematically analyzed transcripts and applied the findings accordingly. |
Assess the impact of counsellor training | Quantitative: Knowledge, attitudes and practices (KAP) surveys (Additional file 1: Box 3) were administered to TB counsellors pre- and post-training. We compared pre-and post-training responses to the KAP survey knowledge questions (20 questions) using Fisher’s exact test and to the attitude questions (21 questions) using Wilcoxon rank-sum test (α < 0.10). We compared total knowledge scores pre- and post-training using a Wilcoxon rank-sum test. Qualitative: A trained social worker conducted a FGD with TB counsellors at the end of the intervention (“post-intervention FGD”), following a semi-structured interview guide. |
Assess implementation and refine intervention | Quantitative: None Qualitative: TB counsellors recorded notes and memos after health talks and counselling sessions, which were reviewed by the study coordinator (NS) and a study team member (BS), discussed with the study team, and informed any ongoing changes to the intervention, as needed. |
Assess impact on TB testing | Quantitative: We performed an interrupted time series analysis using a quasi-Poisson regression model, including calendar month as a fixed effect to account for the background seasonal trend, to compare the weekly number of TB tests pre- and post-intervention. Qualitative: Post-intervention FGD |
Assess impact on TB treatment initiation | Quantitative: We performed univariate and multivariate (adjusting for age, sex and calendar month, without imputing any missing data on confounders) binomial regressions to compare probabilities of treatment initiation in the two periods, and a Mann-Whitney non-parametric test to compare the median treatment delay (i.e., the number of days from testing to starting TB treatment). Qualitative: Post-intervention FGD |
Assess impact on TB treatment outcomes | Quantitative: We performed univariate and multivariate logistic regression analyses (adjusting for age, sex, smear status, and HIV and ART status, without imputing missing confounders) to compare the probability of TB treatment completion. In the main analysis, we compared the study and historical control periods and included all new TB patients in the study period regardless of whether they enrolled into the study (i.e. an intention-to-treat analysis). In our sensitivity analyses, we compared: patients enrolled in the study period to all other patients (in both the study and historical control period); patients enrolled in the study to patients in the historical control period; and patients enrolled to patients not enrolled in the study during study period (Additional file 1: Table 8). Qualitative: Post-intervention FGD |
Explore counsellors’ and patients’ perspectives on the impact, acceptability and feasibility of the intervention | Quantitative: Descriptive analyses of brief exit surveys (Additional file 1: Box 4) that were administered to all enrolled patients who received both counselling sessions. Qualitative: In addition to the post-intervention FGD and brief patient exit surveys, a purposive sample of enrolled patients (aiming for maximum variation in patient characteristics based on age, gender, education, and TB/HIV history) were recruited for one-on-one, in-depth interviews with the study coordinator (NS), following a semi-structured interview guide. All of the collected data (survey responses and transcripts) were thematically analyzed using a constant comparative approach. |
TB counsellor training
Patient recruitment and sampling
Data collection and analysis
Overview
TB diagnostic testing
Treatment initiation
Treatment outcomes
Acceptability and feasibility
Results
Overview
Activity/participant type | No. (%) |
---|---|
Pre-study focus group with clinic staff | 14 (100) |
Counsellors | 7 (50) |
Doctor or assistant doctor | 2 (14.3) |
Nurses | 3 (21.4) |
Administrative staff | 2 (14.3) |
TB counsellor training | 11 (100) |
Group 1 (May 21 – Jul 13) | 7 (63.6) |
Group 2 (Jul 14 – Sep 4) | 4 (36.4) |
Enrolled patients | 84 (100) |
Exit surveys | 57 (67.9) |
In-depth interviews | 13 (15.5) |
Baseline patient characteristic | Study vs historical control period | Study period only | ||||
---|---|---|---|---|---|---|
Historical control | Study | Chi-square p-value | Not enrolled in study | Enrolled in study | Chi-square p-value | |
Baseline patient characteristics | ||||||
Age, mean (SD) | 37.0 (14.7) | 35.7 (13.2) | 0.45 | 37.3 (12.5) | 34.1 (13.7) | 0.12 |
Female (%) | 38 (34.5) | 69 (42.3) | 0.24 | 37 (46.8) | 32 (38.1) | 0.33 |
HIV-positive (%) | 78 (70.9) | 114 (69.9) | 0.97 | 56 (70.9) | 58 (69.0) | 0.93 |
On ART at start of treatment (%) | 40 (51.3) | 47 (41.2) | 0.22 | 30 (53.6) | 17 (29.3) | 0.01 |
Previously treated* (%) | 18 (16.4) | 40 (24.5) | 0.14 | 15 (19.0) | 25 (29.8) | 0.16 |
Smear-positive (%) | 35 (31.8) | 33 (20.2) | 0.04 | 14 (17.7) | 19 (22.6) | 0.60 |
Treatment outcomes | ||||||
Success (Cured/completed) | 50 (45.5) | 75 (46.0) | 0.16 | 45 (53.6) | 30 (38.0) | 0.27 |
Died | 3 (2.7) | 4 (2.5) | 1 (1.2) | 3 (3.8) | ||
Lost to follow-up | 9 (8.2) | 18 (11.0) | 8 (9.5) | 10 (12.7) | ||
Transferred out | 26 (23.6) | 50 (30.7) | 24 (28.6) | 26 (32.9) | ||
Not evaluated | 22 (20.0) | 16 (9.8) | 6 (7.1) | 10 (12.7) |
Study implementation
Clinic engagement and limitations
“I think that approach helped them because they felt included; it did not appear to just come from the department of social work.” - TB counsellor.
Counsellors’ knowledge gaps
“The training at first was scary … when they mentioned that we will be dealing with patients with TB … we were afraid that what if we get infected. But as we get more information during training, we left feeling alright; we understood and being scared had decreased, but we were still scared.” – TB counsellor.
Proficiency and tedium of health talks
“Let’s say go outside in the community … Because at the clinic you end up talking to the same people.” – TB counsellor.
TB testing and treatment initiation
Perceived patient engagement
Quantitative analyses | Qualitative themes | |
---|---|---|
Study implementation | TB counsellors’ median pre-training and post-training TB knowledge score were 50% (IQR 7.5%) and 65% (IQR 17.5%). The median change in score was 12.5% (95%CI = 5.0 to 20.0%)a Enrolled 51.5% (84 out of 163) of all TB patients who started treatment during the study period. Median duration of health talks (n = 58) was 94.1 (± 42.4) minutes | • Clinic engagement and limitations • Counsellors’ knowledge gaps • Proficiency and tedium of health talks |
TB testing & treatment initiation* | Comparing the study period to the historical control period: - Number of diagnostic tests increased by 1.36 times (95%CI 1.23 to 1.58) (see Fig. 2 for observed and expected TB tests performed pre-and post-intervention)b - Probability of treatment initiation increased from 7.8 to 19.0%; with an estimated increase of 10.1% (95%CI 1.5 to 21.3%) after adjusting for potential confoundersc - Median treatment delay decreased from 7.0 days to 4.5 days, a change of 2.5 days (95%CI 2.0 to 3.0 days)d | • Perceived patient engagement • Difficult patient queries |
Treatment retention* | Probability of treatment completion was similar during the study period (45%) and the historical control period (46%). There was an estimated increase during the study period of 4.4% (95%CI −7.3 to 16.0%) after adjusting for baseline confounderse Among those enrolled, 26 (31%) received only the first of two study counselling sessions. | • Improved treatment self-efficacy • Alleviation of anxiety, fears and perceived stigma • Barriers to treatment and counselling |
“I remember a day we were doing a presentation where old people sit … there was a brother who was arguing and saying TB is not curable, and [a woman] stood up and said; ‘I, my child, I had MDR [and] look, I am alive.’ So I was very happy that day because there is evidence, a patient saying for herself that ‘I was in hospital for six months and I was cured and TB is curable.’ You could see the brother calming down, starting to believe because of hearing from a person who was in treatment.” – TB counsellor.
“You see that the person wants to get more information and you see that the information that he is getting he does not want to keep it for himself; he wants to pass it on to another person so they want to understand well.” – TB counsellor.
Difficult patient queries
“Sometimes a problem is that there are patients it [who] are educated, sometimes they have studied the course you are doing [on TB] more than you – you only did it for three days – and he knows more. I came across with that challenge, but I was with one of our colleagues, so I ended up asking her to please answer for me, because the way he was directing the questions, he was challenging me.” - TB counsellor.
“[The patient] was crying having found out that she is positive and TB was found. So it means that she got it all in one time. We had to offer counselling that on one side it is HIV, it is treatable if you take your pills the right way, before we even speak about TB...[but] the training helped because I applied the skills that I was taught, that if a patient it is like this, how you should approach it.” – TB counsellor.
Treatment retention
Improved treatment self-efficacy
“The counsellors were friendly, they showed care in me, and believed in me that I will complete treatment.” – male TB patient, 43.
“Because I saw improvement in how people adhere to medication through counseling, that helps the clinic staff because they … do not have to go back and treat the person for TB [again], so there was improvement in the hospital as a whole.” – TB counsellor.
Alleviation of anxiety, fears and perceived stigma
“The counsellor was very helpful and gave information, gave a chance to ask question … it was not pleasant at all to hear that I had TB, but the counselling was helpful, it helped the me to accept the situation and gave me the hope to live again.” – female TB patient, 48.
“It helped me to realize that TB can affect everyone; before I had a perception that people who get TB stay in informal settlements, attending sessions changed my way of thinking.” – male TB patient, 56.
“A social worker is able to give you time to listen to you, [and discuss] how you will overcome these problems that you say you have; we meet each other halfway, we discuss it … But a nurse won’t have time, the queue is long … she cannot sit with a patient for 45 minutes.” – TB counsellor.
Barriers to treatment and counselling
Theme | Representative quotes from health care workers |
---|---|
Inadequate patient preparation and education | “Now I am rushed … I am teaching you bits and pieces and say you will see the rest on the paper at home because I am rushing for the queue outside.” |
“It seems better at HIV because, you know, HIV like they have a lot of time than us, they have time for testing, they are taught in classes, and they are prepared before they start pills; with TB, you find out today that you have TB, you start taking pills today.” | |
Stigma | “Maybe they will be afraid that they have TB because it will be said if you have TB you will infect [others] while working, in that way it makes them stigmatized.” |
Initial shock and weakness (as hindering education) | “Others you even finish talking to them and they are just shocked, they can’t even hear what you are saying.” |
“Health education is given to TB patients but because they come weak or have errands, some are disorientated” | |
Denial of diagnosis and treatment | “They just want cough mixture and antibiotics … so now for them to come back for you to give them medication - that’s going to be chronic - is a problem, that’s the biggest problem … They are not here thinking they will get TB, they just are here for a quick fix.” |
Transient catchment population | “We are in town … where they get their buses, taxis and all those things, so a person walks in and they are not from our catchment area so maybe they are from Ianskop or wherever … so we have done screening and we see that they have signs and symptoms … they are not going to come back because they are not coming here for that.” |
Difficulties tracing homeless patients | “There are many people who are homeless, some are living in the streets, some in informal settlements so you find that the patient will come in when they are very sick, they come and take medication … As soon as they feel they are a bit better they will go back to their lives of hustling, so they go back and hustle and it becomes difficult for us to even trace them.” |
Job suspension | “We have a problem with employers … employers, once they find out they have TB they stop them from work, so they need letters from doctors that will say whether the person can continue with working or not.” |
“I was still in pain and thinking about my family’s situation and hunger.” – male TB patient, 47.
“Sometimes [the patient] came to the clinic for his date, but he was tired because he arrived in the morning and was in queues; he has gotten his pills why not go home.” – TB counsellor.
“Once [the patient] has been diagnosed with TB, he already has the drive to that ‘I have to cure this’, he is listening to everything you are saying. But when it’s coming to three months, when they are starting to go back to normal … it is where they start to be lost to follow-up, it’s where they go back and become sick.” – TB counsellor.