Background
Methods
Study setting
Study design
Sample size
Selection of respondents
Data collection
Attribute | Level | Attribute definitions for this study |
---|---|---|
DOT Provider | Expert client | An individual who was treated for MDR-TB and recovered with good treatment outcomes. This person serves as an example in their community and helps others overcome a similar condition. |
Family member | An adult older than 18 years living with the MDR-TB patient in the same household. | |
Community health worker | A person with basic health related training, who lives not more than an hour’s walk away from the patient’s home | |
Location | Home | A place where one lives permanently, especially as a member of a family. |
Work | A place of employment to earn a living. It may be formal, informal, self-employed, or having an employer. In this study, this also included school for students. | |
Support type | SMS reminders | An appointment text message sent to a mobile telephone one week prior to the patients follow up clinic visit. |
Call reminders | A telephone call made one week prior to the patients follow up clinic visit at the tertiary hospital for treatment monitoring | |
Travel vouchers | A travel ticket worth 13$ issued to the patient by the tertiary hospital with a date on which to return to the tertiary hospital for treatment monitoring. |
Attributes and levels
Choice Set | Choice set alternatives | Attributes | ||
---|---|---|---|---|
Location of care | DOT provider | Support type | ||
1 | I | work | CHW | Travel vouchers |
II | Home | Expert Client | Call reminders | |
III | Neither | |||
2 | I | Home | Family member | SMS reminders |
II | work | Expert Client | Travel vouchers | |
III | Neither | |||
3 | I | Home | Family member | SMS reminders |
II | work | CHW | Call reminders | |
III | Neither | |||
4 | I | Home | Expert Client | SMS reminders |
II | Home | Family member | Call reminders | |
III | Neither | |||
5 | I | Home | Family member | Travel vouchers |
II | Home | CHW | SMS reminders | |
III | Neither | |||
6 | I | Work | CHW | SMS reminders |
II | Home | Expert Client | Travel vouchers | |
III | Neither | |||
7 | I | Work | Expert Client | SMS reminders |
II | Home | CHW | Call reminders | |
III | Neither | |||
8 | I | Work | Expert Client | Call reminders |
II | Home | CHW | Travel vouchers | |
III | Neither |
Data analysis
Quantitative data
DCE analysis to determine the patients’ preferred MDR-TB CB-DOT model
Qualitative data
Results
Socio-demographics
Characteristics | Number (%), N = 103 |
---|---|
Gender | |
Female | 43 (41.7) |
Male | 60 (58.3) |
Age in years, median (IQR) | 37 (30–47) |
Age categories | |
20–34 | 42 (40.8) |
35–80 | 61 (59.2) |
Marital status | |
Single/Single/Divorced/Separated | 48 (46.6) |
Married | 55 (53.4) |
Occupation | |
Farmer | 37 (35.9) |
Business | 24 (23.3) |
Employed | 33 (32.1) |
Unemployed | 9 (8.7) |
Daily income ($)a | |
< 1$ | 67 (65.1) |
≥1$ | 36 (34.9) |
Education | |
None | 11 (10.8) |
Primary | 58 (56.9) |
Secondary | 24 (23.5) |
Tertiary | 9 (8.8) |
HIV status | |
Negative | 63 (61.2) |
Positive | 40 (38.8) |
Duration on MDR-TB treatment (months)a | |
Median (IQR) | 10 (5–16) |
Categories | |
< 6 months | 31 (30.4) |
≥ 6 months | 71 (69.6) |
Discrete choice model analysis
Preference for specific attributes of community-based care
Attributes and levelsa | Coefficients | 95%CI | P-value | SD | 95%CI | P value† | Relative importance |
---|---|---|---|---|---|---|---|
Constant | 0.52 | 0.30–0.74 | < 0. 01 | - | - | - | - |
DOT provider | 30.3% | ||||||
Family (reference) | |||||||
Community health work | 1.13 | 0.68–1.59 | < 0. 01 | 1.85 | 1.33–2.37 | < 0.01 | |
Expert client | 0.89 | 0.46–1.32 | < 0. 01 | 1.77 | 1.24–2.30 | < 0.01 | |
Location | 33.5% | ||||||
Workplace (reference) | |||||||
Home | 1.25 | 0.91–1.59 | < 0. 01 | 1.19 | 0.80–1.57 | < 0.01 | |
Support | 36.2% | ||||||
SMS (reference) | |||||||
Phone call reminders | 0.70 | 0.41–0.99 | < 0. 01 | 0.19 | 0.95–1.33 | 0.74 | |
Travel vouchers | 1.35 | 1.04–1.65 | < 0. 01 | 0.55 | 0.04–1.05 | 0.033 |
Sub-group analysis
Attributes and levelsa | HIV Negative | HIV Positive | P value† | ||||
---|---|---|---|---|---|---|---|
Coefficient | SD | Relative importance | Coefficient | SD | Relative importance | ||
DOT provider | 34.2 | 24.2 | |||||
Family (reference) | – | – | – | – | |||
Community health work | 1.22 | 1.78 | 0.95 | 2.07 | 0.356 | ||
Expert client | 0.89 | 1.50 | 0.84 | 2.37 | 0.741 | ||
Location | 27.5 | 43.0 | |||||
Workplace (reference) | |||||||
Home | 0.98 | 1.11 | 1.69 | 1.26 | 0.042 | ||
Support | 38.4 | 32.8 | |||||
SMS (reference) | |||||||
Phone call reminders | 0.76 | 0.56 | 0.56 | 0.01 | 0.668 | ||
Travel vouchers | 1.37 | 0.47 | 1.29 | 0.53 | 0.582 |
Attributes and levelsa | Age 20–34 years | Age ≥ 35 years | P value | ||||
---|---|---|---|---|---|---|---|
Coefficient | SD | Relative importance | Coefficient | SD | Relative importance | ||
DOT provider | 28.4 | 58.6 | |||||
Family (reference) | – | – | – | – | |||
Community health work | 0.80 | 2.25 | 1.37 | 1.57 | 0.016 | ||
Expert client | 1.13 | 2.18 | 0.79 | 1.60 | 0.888 | ||
Location | 40.7 | 33.7 | |||||
Workplace (reference) | |||||||
Home | 1.62 | 1.65 | 1.09 | 0.92 | 0.495 | ||
Support | 30.9 | 7.7 | |||||
SMS (reference) | |||||||
Phone call reminders | 0.87 | 0.58 | 0.62 | 0.06 | 0.743 | ||
Travel vouchers | 1.23 | 0.76 | 1.43 | 0.21 | 0.169 |
Attributes and levelsa | On treatment < 6 months | On treatment ≥ 6 months | P value | ||||
---|---|---|---|---|---|---|---|
Coefficient | SD | Relative importance | Coefficient | SD | Relative importance | ||
DOT provider | 16.7 | 36.7 | |||||
Family (reference) | – | – | – | – | |||
Community health work | 0.58 | 1.94 | 1.49 | 1.77 | 0.018 | ||
Expert client | 0.32 | 1.79 | 1.16 | 1.87 | 0.017 | ||
Location | 48.0 | 27.8 | |||||
Workplace (reference) | |||||||
Home | 1.67 | 1.27 | 1.13 | 1.16 | 0.169 | ||
Support | 35.3 | 35.5 | |||||
SMS (reference) | |||||||
Phone call reminders | 0.73 | 0.99 | 0.66 | 0.11 | 0.546 | ||
Travel vouchers | 1.23 | 0.33 | 1.44 | 0.62 | 0.543 |
Preferred hypothetical models (combination of attributes) of community-based care
Profile | Utility score | Rank |
---|---|---|
H2 CHW/Treatment delivered at home/Travel voucher | 4.25 | 1 |
F2 Expert clients/Treatment delivered at home/Travel voucher | 4.01 | 2 |
G2 CHW/Treatment delivered at home/Phone call reminder | 3.61 | 3 |
A2 Expert client/Treatment delivered at home/Phone call reminder | 3.36 | 4 |
E1 Family member/Treatment delivered at home/Travel voucher | 3.12 | 5 |
A1 CHW/Treatment delivered at work/Monthly travel voucher for monthly appointments | 3.00 | 6 |
E2 CHW/Treatment delivered at home/SMS reminder for monthly appointments | 2.90 | 7 |
B2 Expert client/Treatment delivered at work/Monthly travel voucher for monthly appointments | 2.76 | 8 |
D1 Expert client/Treatment delivered at home/SMS reminder for monthly appointments | 2.66 | 9 |
D2 Family member/Treatment delivered at home/Phone call reminder for monthly appointments | 2.48 | 10 |
C2 CHW/Treatment delivered at work/Phone call reminder for monthly appointments | 2.36 | 11 |
H1 Expert client/Treatment delivered at work/Phone call reminder for monthly appointments | 2.11 | 12 |
C1 Family member/Treatment delivered at home/SMS reminder for monthly appointments | 1.77 | 13 |
B1 Family member/Treatment delivered at home/SMS reminders for monthly appointments | 1.77 | 13 |
C1 Family member/Treatment delivered at home/SMS reminder for monthly appointments | 1.66 | 15 |
F1 CHW/Treatment delivered at work/SMS reminder for monthly appointments | 1.41 | 16 |
Qualitative results
DOT provider
Family members were least preferred and viewed as unable to offer the support needed.“A community health worker encourages you to take medicine than any other person. Also provides counselling to the patient and explains the benefit of taking medicines on time.” [20yr., Female, Single]“I prefer an expert client to support me since he has been through the same situation. Expert client has the best experience ever [I] will be able to share with him.” [33yr., Male, Married]“I prefer a CHW because they are knowledgeable, and I can trust them with my life.” [54yr., Male, Married]
“... family members, they sympathize so much and may discourage you from sticking to your treatment schedules as required and also they lack experience with this type of TB disease.” [22yr., Female, Single]
Location of care
The workplace was not preferred by the majority of the respondents. It was associated with stigma and fear for loss of employment or clients.“The treatment at home also is a bonus, because the community cannot discriminate if confidentiality is kept by the expert client." [29yr., Female, Divorced/separated]“Treatment at home and monthly travel vouchers for monthly appointments is my preferred choice because there is time management while taking drugs since no out movement.”[66yr., Male, Married]“It becomes less costly when I get treatment at home.” [31yr., Male, Married]
“I feel confidentiality is not possible at my workplace where I could easily be seen and get stigmatized.” [22yr., Female, Divorced/separated]“… if visited at work, I could easily suffer from the gossip by workmates when they eventually learn about my condition, this could easily make me lose clients.” [55yr., Female, Divorced/separated]
Support type
“Monthly travel vouchers are the best for me because I will be knowing that transport is readily available and even the ticket will be reminding me of the clinic appointment date.” [40yr., Male, Married]“…because the money given for the travel voucher, the balance from it I can use it to buy other things and also do farming with it.” [52yr., Male, Married]
“The message (SMS) reminders would work for me since am partially deaf and cannot easily hear through a phone call….” [43yr., Female, Divorced/separated]“….SMS reminders are not good for me because I don't know how to read but may be if they call me and give transport to the clinic.” [40yr., Male, Married]