Introduction
Mycobacterium tuberculosis, the infectious agent that causes multi-drug resistant tuberculosis (MDR-TB), is resistant to at least rifampicin and isoniazid. Direct infection can cause the disease to spread, or it can develop secondary to improper management of tuberculosis among drug susceptible tuberculosis cases and associated poor adherence [
1].
Multidrug-resistant strains of mycobacterium tuberculosis have recently emerged, which makes achieving “End TB Strategy” more difficult [
2]. Multi drug resistant tuberculosis (MDR-TB) has been found to increasingly pose a serious threat to global and Ethiopian public health sector. Despite the fact that a number of risk factors for MDR-TB have been identified through various research designs, the epidemiology of this disease is complex, contextual, and multifaceted [
1]. Quantitative studies demonstrate that prior treatment history [
3‐
7], interrupted drug supply [
8], inappropriate treatments and poor patient compliance [
3,
7,
9], poor quality directly observed treatment short course (DOTS), poor treatment adherence [
10], age [
5], and malnutrition [
11] were factors associated with multi drug resistant TB.
Globally, an estimated 20% of previously treated cases and 3.3% of new cases are thought to have MDR-TB; these levels have essentially not changed in recent years. Globally, 160,684 cases of multidrug-resistant TB and rifampicin-resistant TB (MDR/RR-TB) were notified in 2017, and 139,114 cases were enrolled into treatment in 2017 [
12]. A systematic review in Ethiopia reported 2% prevalence of MDR-TB [
3] that is higher than what is observed in Sub-Saharan Africa, 1.5% [
13]. The prevalence of MDR-TB, according to the national drug-resistant tuberculosis (DR-TB) sentinel report, was 2.3% among newly diagnosed cases of TB and 17.8% among cases of TB who had already received treatment,. This suggests a rising trend in the prevalence of TB drug resistance compared to the results of the initial drug-resistant TB survey carried out in Ethiopia from 2003 to 2005 [
14].
Ethiopia has placed strategies into place that emphasize political commitment, case finding, appropriate treatment, a continuous supply of second-line anti-TB medications of high quality, and a recording system. Due to other competing health priorities, the nation is having difficulty accelerating the scale-up of the detection, enrollment and treatment of drug-resistant TB patients [
15,
16]. To address these issues, the nation switched from a hospital-based to a clinic-based ambulatory model of care, which has allowed MDR-TB services to quickly decentralize and become more accessible. Accordingly, the nation has set up health facilities to act as either treatment initiating centers (TIC) or treatment follow-up centers (TFC) or both for improved referral and communication methods [
15].
One of the key components of the “End TB strategy” is engagement of health care professionals in the prevention and management of multidrug resistant tuberculosis [
17]. Inadequate engagement of healthcare providers is one aspect of the healthcare system that negatively influences MDR-TB prevention and control efforts [
17]. This may be manifested in a number of ways, including inadequate understanding of drug-resistant tuberculosis, improper case identification, failure to initiate treatment again, placement of the wrong regimens, improper management of side effects and poor infection prevention [
1]. These contributing factors are currently being observed in Ethiopia [
18], Nigeria [
7,
19,
20] and other countries [
21,
22]. According to a study conducted in Ethiopia, MDR-TB was linked to drug side effects from first-line treatments, being not directly observed, stopping treatment for at least a day, and retreating with a category II regimen [
17].
This may be the result of a synergy between previously investigated and other contextual factors that have not yet been fully explored, such as professional engagement, beliefs, and poor preventive practices. The engagement of health professionals in MDR-TB prevention and control is assessed using a number of composite indicators. Health professionals may interact primarily inside the healthcare facilities. Typically, they play a significant role in connecting healthcare services with neighborhood-based activities [
17]. One of the main research areas that have not sufficiently addressed is evidence indicating the status of healthcare professionals’ engagement and contextual factors in MDR-TB prevention and management.
It is increasingly urgent to identify additional and existing factors operating in a particular context that contribute to the development of the disease in light of the epidemic of drug resistance, including multi-drug resistance (MDR-TB) and extensively drug resistant TB (XDR-TB) in both new and previously treated cases of the disease [
23]. In order to develop and implement control measures, it is therefore essential to operationally identify a number of contextual factors operating at the individual, community, and health system level.
Therefore, the overall purpose of this study was to explore the level of engagement of health care providers and contextual factors hindering/enabling the prevention and provision of patient-centered care for MDR-TB in health facilities, DOTS services centers and MDR-TB treatment initiation center [TIC], in Hadiya Zone, Southern Ethiopia.
Methods
Qualitative approach and research paradigm
Descriptive phenomenological qualitative study design was employed to explore factors influencing engagement of health professionals in MDR-TB prevention and management and thematic technique was employed for the analysis of the data.
Researchers’ characteristics and reflexivity
Three Principal investigators conducted this study. Two of them had Masters of public health in Epidemiology and Reproductive health and PhD candidates and the third one had Bachelor’s degree in public health with clinical experience in the area of Tuberculosis prevention and management and MPH in Biostatistics. The principal investigators have research experience with published articles in different reputable journals. There were no prior contacts between researchers and participants before the study whereas researchers have built positive rapport with study participants during data collection to foster open communication and trust and had no any assumptions and presuppositions about the research topic and result.
Context/ study setting and period
The study was conducted between 2 and 9 May, 2019 in Hadiya Zone with more than 1.7 million people residing in the Zone. There are 300 health posts, 63 health centers, 3 functional primary hospitals and 1 comprehensive specialized hospital in the Zone. Also, there are more than 350 private clinics and 1 private hospital in the Zone. All of the public health facilities and some private health facilities provide directly observed short course treatment (DOTS) service for tuberculosis patients. There are more than eight treatment initiation centers (TICs) for MDR-TB patients in Hadiya Zone. MDR-TB (Multidrug-resistant tuberculosis) treatment initiation centers are specialized facilities that provide comprehensive care, diagnosis and treatment initiation, psychosocial support, and follow up services to individuals with MDR-TB. The linkage between MDR-TB treatment initiation centers and other healthcare facilities lies in the coordination of care, referral pathways, and collaboration to ensure comprehensive and integrated care for individuals with MDR-TB. Overall, healthcare providers play a crucial role in the management of MDR-TB by providing specialized care, ensuring treatment adherence, monitoring progress and outcomes, and supporting individuals in achieving successful treatment outcomes and improved health.
Units of study and sampling strategy
Our study participants were health care professionals working in MDR-TB TICs in both private and public health facilities, and providing DOTS services, MDR-TB program leaders in treatment initiation centers, as well as TB focal persons, disease prevention and health promotion focal person, and project partners from district health offices. The study involved four focus group discussion (FGDs) and five key informants’ interview (KII) with a total of 26 participants to gather the necessary information. Expert purposive sampling technique was employed and sample size was determined based on the saturation of idea required during data collection process.
Data collection methods and instruments
Focus group discussion and face to face key informants’ interviews were employed to collect the data. We conducted a total of four FGD and five key informants’ interviews with participants chosen from DOTS providing health facilities and MDR-TB program leaders in treatment initiation centers, as well as TB focal persons and project partners from district health offices and disease prevention and health promotion focal person. One of the FGDs was conducted among health professionals from the public MDR-TB treatment initiation centers. Three FGDs were conducted among disease prevention and health promotion focal persons, TB focal persons and DOTS providers in public health facilities (health centers).
An observation checklist was developed to assess the general infection prevention and control measures used by specific healthcare facilities in the study area. We used unstructured FGD guide, key informant interview guide, observation checklist and audio recorders to collect primary data and it was collected using local language called Amharic. Prior to data collection, three people who are not among principal investigators with at least a master’s degree in public health and prior experience with qualitative research were trained by principal investigators. Three of them acts as a tape recorder, a moderator, and as a note taker alternatively. The length of FGD ranged from 58 to 82 min and that of key informants’ interview lasted from 38 to 56 min.
Data processing and data analysis
Memos were written immediately after interviews followed by initial analysis. Transcription of audio records was performed by principal investigators. The audio recordings and notes were refined, cleaned and matched at the end of each data collection day to check for inconsistencies, correct errors, and modify the procedures in response to evolving study findings for subsequent data collection. Transcribed interviews, memos, and notes from investigator’s observation were translated to English and imported to Open Code 4.02 [
2] for line by line coding of data, and categorizing important codes (sub theming). The pre-defined themes for MDR-TB prevention and control engagement were used to thematize the line-by-line codes, categories, and meanings using thematic analysis. Finally, the phenomenon being studied was explained by emerging categories and themes. Explanations in themes were substantiated by participants’ direct quotations when necessary.
Trustworthiness
Phone calls and face to face briefing were requested from study participants when some expressions in the audio seems confusing while transcripts were performed. To ensure the credibility of the study, prolonged engagement was conducted, including peer debriefing with colleagues of similar status during data analysis and inviting available study participants to review findings to ensure as it is in line with their view or not. Memos of interviews and observation were crosschecked while investigator was transcribing to ensure credibility of data as well as to triangulate investigator’s categorizing and theming procedures. For transferability, clear outlines of research design and processes were provided, along with a detailed study context for reader judgment. Dependability was ensured through careful recording and transcription of verbal and non-verbal data, and to minimize personal bias, scientific procedures were followed in all research stages. Conformability was maintained by conducting data transcription, translation, and interpretation using scientific methods. Researchers did all the best to show a range of realities, fairly and faithfully. Finally, an expert was invited to put sample of codes and categories to emerged corresponding categories and themes respectively.
Discussion
Engagement of individual healthcare providers is one of the peculiar interventions to achieve the goal of universal access to drug resistance tuberculosis care and services [
17]. Healthcare providers engagement in detecting cases, treating and caring for multidrug resistant tuberculosis (MDR-TB) may be influenced by various intrinsic (individual provider factors) and extrinsic (peer, health system, political and other factors) [
15]. Our study explored engagement of individual DOTS providers and factors that influence their engagement in MDR-TB prevention and management service. This is addressed through five emergent themes and subthemes as clearly specified in our results section.
The findings showed patients’ socioeconomic constraints were important challenges that influence health professionals’ engagement, and provision of MDR-TB prevention and management services. Although approaches differ, studies in Ethiopia [
24], South Africa [
25] and India [
26,
27] documented that such factors influence health providers’ engagement in the prevention and management of multi drug resistant tuberculosis. Again, the alleviation of these factors demands the effort from patients, stakeholders working on TB, others sectors, and the healthcare system so that healthcare providers can deliver the service more effectively in their day-to-day activities and will be more receptive to the other key factors.
We explored participants’ experiences on how patients’ awareness about drug sensitive or multi drug resistant tuberculosis influenced their engagement. Accordingly, participants encountered numerous gaps that restricted their interactions with TB/MDR-TB patients. In fact, our study design and purposes vary, studies [
28‐
30] indicated that patients awareness influenced providers decision in relation to MDR-TB services and patients’ awareness status is among factors influencing healthcare providers’ decision making about the care the MDR-TB patient receives. As to our knowledge, patients’ perceived fear of discrimination was not documented whether it had direct negative impact on reducing providers’ engagement. Therefore, patients’ awareness creation is an important responsibility that needs to be addressed by the community health development army, health extension workers, all other healthcare providers and stakeholder for better MDR-TB services and patient outcomes.
Our study indicates that healthcare providers perceived that they would be exposed to MDR-TB while they are engaged. Some of the participants were more concerned about the disadvantages of engagement in providing care to MDR-TB patients which were predominantly psychological and physical pressure. In this context, the participants emphasized that engagement in MDR-TB patient care is “always being at risk” and expressed a negative attitude. This finding is similar to what has been demonstrated in a cross-sectional study conducted in South Africa in which majority of healthcare providers believed their engagement in MDR-TB services would risk their health [
21].
However, majority of the healthcare providers demonstrated perceived fear of exposures mainly due to poor infection prevention practices and substandard organization of work environment in most TB/MDR-TB units. This is essentially reasonable fear, and needs urgent intervention to protect healthcare providers from worsening/reducing their effective engagement in MDR-TB patient care. On the other side of the coin, perceived risk of occupational exposure to infection could be source for taking care of oneself to combat the spread of the infection.
In our study, healthcare provider’s capability (competence) also had an impact on their ability to engage in prevention and management of MDR-TB. Here, participants had frequently raised their and other healthcare providers’ experience regarding skill gaps, negative attitude towards the service unit they were working in, ineffective use of MDR-TB guideline, poor infection prevention practices and commitment. In addition, many health professionals report serious problems regarding case identification and screening, drug administration, and side effect management. These findings were supported by other studies in Ethiopia [
7] and in Nigeria [
19,
20]. This implies an urgent need for training of health care worker on how to engage in prevention and management of multidrug resistant TB.
Moreover, our findings provide insights into the role of community TB prevention actors, currently functioning health system, and colleagues and other stakeholders’ regarding healthcare providers’ engagement. Participants emphasized that support from community TB prevention actors is a key motivation to effectively engage on management and prevention roles towards MDR-TB. Evidence shows that community TB prevention is one of the prominent interventions that study participants would expect in DOTS provision as community is the closest source of information regarding the patients [
31,
32].
Similarly, all participants had pointed out the importance of support from a health system directly or indirectly influence their engagement in the prevention, diagnosis, treatment, and management of MDR-TB. Researches indicated that health system supports are enabling factors for healthcare providers in decision making regarding TB/MDR-TB prevention and treatment [
33]. This problem is documented by the study done in Ethiopia [
22]. In addition, support from colleagues and other stakeholders was also a felt need to engage in MDR-TB which was supported by the World Health Organization guideline which put engagement in preventing MDR-TB and providing patients centered care needs collaborative endeavor among healthcare providers, patients, and other stakeholders [
17].
Participants showed that there were poor linkage among/within DOTS providers working in health post (extension workers), health centers, hospitals and MDRTB treatment initiation centers. Our finding is consistent with a research in South Africa which shows poor health care attitude is linked to poor treatment adherence [
34]. Our study implies the need for further familiarization especially on clinical programmatic management of drug resistant tuberculosis. Moreover, program managers need to follow health professionals’ engagement approaches recommended by the World Health Organization: End TB strategy [
17].
Limitations of the study
There are some limitations that must be explicitly acknowledged. First, participants from private health facilities were very few, which might have restricted the acquisition and incorporation of perspectives from health care providers from private health care facilities. Second, healthcare providers’ engagement was not measured from patient side given that factors for engagement may differ from what has been said by the healthcare provides. Third, power relationships especially among focus group discussant in MDR-TB treatment initiation centers might have influenced open disclosures of some sensitive issues.
Conclusion
The study showed how healthcare provider’s engagement in MDR-TB management and prevention was influenced. Accordingly, patient’s underlying causes, seeking support, perceived occupational exposure, healthcare provider’s incompetence and health facilities poor linkage were identified from the analysis. Weak community TB prevention efforts, poor health system support and support from colleagues, health care providers’ incompetence and health facilities poor linkage were among identified factors influencing engagement in MDR – TB prevention and management. Therefore, measures need to be in place that avert the observed obstacles to health professionals’ engagement including further quantitative studies to determine the effects of the identified reasons and potential factors in their engagement status.
Furthermore, our findings pointed out the need for additional training of service providers, particularly in clinical programmatic management of drug-resistant tuberculosis. Besides, program managers must adhere to the World Health Organization’s recommendations for health professional engagement. Higher officials in the health sector needs to strengthen the linkage between health facilities and service providers at different levels. Community awareness creation to avoid fear of discrimination including provision of support for those with MDR-TB is expected from health experts through implementation of social behavioral change communication activities.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.