Preferential adherence to antiretroviral therapy over tuberculosis treatment: A qualitative study of drug-resistant TB/HIV co-infected patients in South Africa

Adherence to antiretroviral therapy (ART) and second-line antituberculosis medications is essential to achieve successful outcomes among individuals co-infected with HIV and multi or extensively drug-resistant TB (M/XDR-TB). In 2012–2013, we designed a qualitative study to explore barriers to adherence in KwaZulu-Natal, South Africa. We conducted six focus groups comprising 23 adults receiving treatment for either MDR-TB (n = 2) or XDR-TB (n = 21); 17 were on concurrent ART. Participants expressed a preference for ART over M/XDR-TB treatment as a result of greater tolerability, lower pill burden and a commitment to ART. Treatment outcomes and the social morbidity associated with M/XDR-TB, characterised by public notification, stigma and social isolation, were perceived to be worse than with HIV. Poor communication, low patient involvement and provider supervision of treatment exacerbated participants' negative experiences with TB care. To improve adherence, it is critical that new regimens for drug-resistant TB be developed with better efficacy, lower pill burden and fewer adverse effects. For the first time, such improved regimens are on the horizon. In parallel and equally important is the implementation of a cohesive approach that promotes patient involvement, empowerment and treatment literacy for HIV and for TB.     

Quality of life among patients receiving palliative care in South Africa and Uganda: a multi-centred study

Background

Quality of life (QOL) is a core outcome of palliative care, yet in African settings there is a lack of evidence on patients' levels of QOL. We aimed to describe QOL among patients with incurable, progressive disease receiving palliative care in South Africa and Uganda, to compare QOL in cancer and HIV, to determine how domains of QOL correlate with overall QOL, and compare levels of QOL in this population with those in other studies using the same tool.

Methods

A cross-sectional survey was conducted using the Missoula Vitas Quality of Life Index (MVQOLI), a 26-item QOL questionnaire with five subscales (Function, Symptom, Interpersonal, Well being, Transcendent) covering physical, social, psychological and spiritual domains and one global QOL item. One item in each subscale assesses the subjective importance of the domain on a score from 1 (least important) to 5 (most important), used to weight the contribution of the subscale towards the Total QOL score. The tool was translated into 6 languages and administered to consecutively recruited patients at four facilities in South Africa and one in Uganda.

Results

285 patients were recruited, with a mean age of 40.1; 197 (69.1%) were female. Patients' primary diagnoses were HIV (80.7%), cancer (17.9%) and other conditions (1.4%). The mean global QOL score was 2.81 (possible range 0 (worst) to 5 (best)); mean Total score 17.32 (possible range 0 to 30). Patients scored most poorly on Function (mean 0.21), followed by Well being (2.59), Symptoms (5.38), Transcendent (5.50), Interpersonal (9.53) (possible range for subscale scores -30 to 30). Most important to patients were: close relationships (mean 4.13), feeling at peace (4.12), sense of meaning in life (4.10), being active (3.84), physical comfort (2.58). Cancer patients were predominantly recruited at three of the sites; hence comparison with HIV-infected patients was restricted to these sites. HIV+ patients (n = 115) scored significantly worse than cancer patients (n = 50) on Well being (Z = -2.778, p = 0.005), Transcendence (Z = -2.693, p = 0.007) and Total QOL (Z = -2.564, p = 0.01). Global QOL score was most weakly correlated with Total QOL (r = 0.37) and the Transcendent subscale was most highly correlated (r = 0.77) (both p < 0.001). Patients receiving palliative care in South Africa and Uganda exhibited significantly poorer QOL compared to similar populations in the USA.

Conclusions

Feeling at peace and having a sense of meaning in life were more important to patients than being active or physical comfort, and spiritual wellbeing correlated most highly with overall QOL. It is therefore vital to identify and meet the psychological and spiritual care needs of patients, as well as to assess and treat pain and other symptoms. Our finding that patients scored most poorly on the Function domain warrants further research.     

Costs of measures to control tuberculosis/HIV in public primary care facilities in Cape Town, South Africa

OBJECTIVE: To measure the costs and estimate the cost-effectiveness of the ProTEST package of tuberculosis/human immunodeficiency virus (TB/HIV) interventions in primary health care facilities in Cape Town, South Africa. METHODS: We collected annual cost data retrospectively using ingredients-based costing in three primary care facilities and estimated the cost per HIV infection averted and the cost per TB case prevented. FINDINGS: The range of costs per person for the ProTEST interventions in the three facilities were: US$ 7-11 for voluntary counselling and testing (VCT), US$ 81-166 for detecting a TB case, US$ 92-183 for completing isoniazid preventive therapy (IPT) and US$ 20-44 for completing six months of cotrimoxazole preventive therapy. The estimated cost per HIV infection averted by VCT was US$ 67-112. The cost per TB case prevented by VCT (through preventing HIV) was US$ 129-215, by intensified case finding was US$ 323-664 and by IPT was US$ 486-962. Sensitivity analysis showed that the use of chest X-rays for IPT screening decreases the cost-effectiveness of IPT in preventing TB cases by 36%. IPT screening with or without tuberculin purified protein derivative screening was almost equally cost-effective. CONCLUSION: We conclude that the ProTEST package is cost saving. Despite moderate adherence, linking prevention and care interventions for TB and HIV resulted in the estimated costs of preventing TB being less than previous estimates of costs of treating it. VCT was less expensive than previously reported in Africa.     

Bank accounts for public primary health care facilities: Reflections on implementation from three districts in Tanzania

Health care financing reforms are gaining popularity in a number of African countries to increase financial resources and promote financial autonomy, particularly at peripheral health care facilities. The paper explores the establishment of facility bank accounts at public primary facilities in Tanzania, with the intention of informing other countries embarking on such reform of the lessons learned from its implementation process. A case study approach was used, in which three district councils were purposively sampled. A total of 34 focus group discussions and 14 in‐depth interviews were conducted. Thematic content analysis was used during analysis. The study revealed that the main use of bank account revenue was for the purchase of drugs, medical supplies, and minor facility needs. To ensure accountability for funds, health care facilities had to submit monthly reports of expenditures incurred. District managers also undertook quality control of facility infrastructure, which had been renovated using facility resources and purchases of facility needs. Facility autonomy in the use of revenue retained in their accounts would improve the availability of drugs and service delivery. The experienced process of opening facility bank accounts, managing, and using the funds highlights the need to strengthen the capacity of staff and health‐governing committees.     

Quality of life and functional health of primary care patients.

Quality of life and functional health were measured cross-sectionally for 314 adult ambulatory primary care patients in a rural clinic and found to be much better for patients with low severity of illness who required no confinement to home because of health problems, than for patients with high severity of illness who required confinement. Severity of illness was the strongest predictor for patient-reported physical health function and for patient quality of life when assessed by the health provider. Confinement was the strongest predictor for patient quality of life when assessed by the patient. There was very little agreement between patient-assessed and provider-assessed quality of life. Family stress was the strongest predictor of function in terms of mental health, social health, general health, self-esteem, anxiety, and depression. These data suggest that clinicians should direct increased attention to patient-assessed quality of life, patient-reported functional health status, and psychosocial factors such as family stress in an effort to improve medical outcomes.     

Delays and unmet need for health care among adult primary care patients in a restructured urban public health system

OBJECTIVES: We estimated the prevalence and determinants of delayed and unmet needs for medical care among patients in a restructured public health system. METHODS: We conducted a stratified cross-sectional probability sample of primary care patients in the Los Angeles County Department of Health Services. Face-to-face interviews were conducted with 1819 adult patients in 6 languages. The response rate was 80%. The study sample was racially/ethnically diverse. RESULTS: Thirty-three percent reported delaying needed medical care during the preceding 12 months; 25% reported an unmet need for care because of competing priorities; and 46% had either delayed or gone without care. CONCLUSIONS: Barriers to needed health care continue to exist among patients receiving care through a large safety net system. Competing priorities for basic necessities and lack of insurance contribute importantly to unmet health care needs.     

Assessing local health needs in primary care: understanding and experience in three English districts.

BACKGROUND: Assessing the health needs of a local population has been promoted as a key component in effective targeting of healthcare services and quality improvement. The understanding and experience of assessing health needs in general practice were investigated in three English districts. AIM: To identify the issues surrounding the potential for assessing health needs in primary care. METHOD: Postal survey of 347 general practices in three health authorities. Telephone interviews with a random stratified sample of 35 general practitioners. RESULTS: Although most practices identified assessing health needs as important, it is clear that this identification was typically based on an understanding of assessing needs as primarily focused on individual patient care, based on clinical priorities and involving practice held data. Most practices had not undertaken local consultation, whatever their understanding of assessing health needs. The few practices which had completed population oriented, proactive assessment of needs considered it to have led to tangible improvements in clinical or practice management. Overall, there was apparent confusion over the nature and purpose of assessing needs, although the principled aims and objectives of a population oriented, proactive component to primary care were generally upheld. The need for additional resources and support was identified. In four out of the five cases where specifically population based assessment of health needs had been undertaken, the local public health department had been involved. CONCLUSION: The value of the concept of assessing health needs in primary care holds considerable uncertainty and ambivalence. The findings from this study show that any attempts to promote assessing needs into primary care which focus either primarily or exclusively on the provision of "education" are unduly simplistic. More fundamental questions about the perceived relevance and opportunities for assessing health needs should be considered if primary care groups are to meet future commissioning challenges.     

Occupational health policies and practices related to tuberculosis in health care workers in KwaZulu-Natal,South Africa

Setting:

Three district hospitals in KwaZulu-Natal, South Africa, with specialized drug-resistant tuberculosis (TB) wards.

Objective:

To increase understanding of the implementation of occupational health (OH) and infection control (IC) guidelines for the prevention and control of TB among health care workers (HCWs).

Design:

An operational cross-sectional study conducted between July and September 2011, consisting of interviews with OH and IC nurses and chart review of OH medical records.

Results:

Although general national and provincial OH policies are in place, no specific OH policies exist for hospital settings. Two of three hospitals had a full-time OH nurse and all had a full-time IC nurse. All hospitals offered TB symptom screening; however, only 19% of HCWs were screened in 2010. TB incidence among HCWs was 1958 per 100 000 population in 2010. All hospitals offered HIV counseling and testing; however, only 22% of staff were tested across sites. Two hospitals offered isoniazid preventive therapy to HIV-positive staff and reassigned these staff to low TB risk areas.

Conclusions:

While OH policies and procedures are in place, implementation of these policies and procedures is inconsistent. This potentially places HCWs at risk of acquiring TB. These findings support the need for strengthening OH and IC services to prevent TB.     

Quality of life among diabetic patients in Swedish primary health care and in the general population: comparison between 1992 and 1995

To assess change over time in health-related quality of life (HRQoL) in diabetic patients in primary health care and differences to general Swedish population samples, 341 diabetic subjects in 1992 and 413 in 1995, aged 20–84 years, were chosen from three community health centres (CHCs) in the Metropolitan Stockholm area and compared to controls matched by age and sex in randomly selected samples of 2,366 subjects in 1991 and 2,500 in 1995 from the general population. HRQoL was assessed by the Swedish Health-Related Quality of Life Survey (SWED-QUAL), adapted from the Medical Outcomes Study, which measures aspects of physical, mental, social and general health in 13 scales. Information on diabetic and general medical data were extracted from the medical records at the CHCs. HRQoL was lower in diabetic subjects compared with the general population in both 1992 and 1995 in all scales except family functioning and marital functioning. The level of HRQoL did not change significantly between the diabetic samples, but decreased in the population samples, making the difference compared to diabetic patients smaller in five of the scales. The most significant predicting factors for the SWED-QUAL results in diabetic patients in 1995 were the vascular and non-vascular co-morbidity.     

Quality of life in patients with heart failure: the perspective of primary health care

Objective

To measure and identify the dimensions and determinants of health-related quality of life (HRQoL) in patients with chronic heart failure.

Methods

We performed a cross-sectional study, in which HRQoL was measured with the short-form (SF)-36 and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) in 544 clinically-stable patients with chronic heart failure managed by 97 primary care physicians.

Results

The mean age of the patients was 77.6 years (SD: 9.9) and was significantly higher in women. A total of 31.2% were in New York Heart Association (NYHA) grade III-IV and 88.6% had at least one chronic condition. In both questionnaires, physical dimensions scored worse than emotional dimensions. After adjustment was made for multiple regression, seven variables entered into one of the five models and explained between 22% and 36% of the variance.

Conclusions

HRQoL in patients with chronic heart failure is impaired across all domains. Being female and being in NYHA functional class III-IV, as well as other factors such as depression, osteoarticular disease, hospital admission, body mass index and age, were associated with poorer self-perceived HRQoL.     

Anticipated tuberculosis stigma among health professionals and Haitian patients in South Florida

This paper compares tuberculosis-related stigma perceptions of health professionals with that of local patient populations, and examines these in relation to other measures of anticipated distress. Comparison groups were service providers and Haitian American patients diagnosed with latent TB (LTBI). Providers consistently rated LTBI higher on anticipated stigma than patients both overall and for internal perceptions and emotions, external perceptions and actions, and Haitian identity. Health professionals were almost five times more likely than patients to report the possibility of other types of psychosocial distress. The findings are consistent with previous studies reporting a higher degree of perceived stigma among unaffected populations compared with people diagnosed with a medical condition. Results suggest that providers may overestimate the likelihood that patients with a stigmatized condition will experience negative consequences. This may negatively affect adherence to TB testing guidelines because of confidentiality concerns. The implications for achieving national TB elimination goals are discussed.     

邯郸某贫困县中小学结核病健康教育干预效果评价

目的 评价邯郸市中小学校结核病健康教育干预对师生结核病防治知识水平的影响,为学生健康教育措施的制订提供依据.方法 在规定时间内,对随机抽取的邯郸市某贫困县全体中小学师生实施结核病健康教育干预,并于干预前后对师生进行结核病防治知识问卷调查.结果 教师、中学生、小学生结核病防治知识总体知晓率干预前分别为64.9％,56.1％和38.7％,干预后分别为89.8％,89.2％,92.8％,差异均有统计学意义(P值均＜0.01).结论 在中小学校开展结核病健康教育,能显著提高师生结核病防治知识知晓率.     

云南省3县TB/HIV患者结核病知识知晓率及影响因素分析

目的分析云南省TB/HIV患者的流行特征和结核病知识知晓率及其影响因素,为进一步加强云南省结核病健康促进和健康教育工作提供理论依据。方法对2010年1月—2012年6月期间218名TB/HIV患者进行结核病知识知晓率的问卷调查。统计分析采用单因素分析和Logistic回归分析。结果调查对象结核病知识综合得分为（8.23±2.01）分。职业（χ2=22.515）、婚姻状况（χ2=50.110）、患者来源（χ2=6.378）、住院治疗（χ2=3.915）、管理方式（χ2=4.579）及抗病毒治疗（χ2=11.342）各组间差异均有统计学意义（P均〈0.05）。Logistic回归分析显示,影响结核病知识综合得分的因素有患者来源（Waldχ2=6.277,P=0.02）和抗病毒治疗（Waldχ2=10.678,P〈0.001）。结论云南省TB/HIV患者结核病核心信息总知晓率为82.29%,高于全国结核病防治知识80%的目标。应根据不同地区、不同人群的特点,针对性的制作各种不同的宣传材料,积极宣传结核病的防治知识。     

Impact of community tracer teams on treatment outcomes among tuberculosis patients in South Africa

ABSTRACT: BACKGROUND: Tuberculosis (TB) indicators in South Africa currently remain well below global targets. In 2008, the National Tuberculosis Program (NTP) implemented a community mobilization program in all nine provinces to trace TB patients that had missed a treatment or clinic visit. Implementation sites were selected by TB program managers and teams liaised with health facilities to identify patients for tracing activities. The objective of this analysis was to assess the impact of the TB Tracer Project on treatment outcomes among TB patients. METHODS: The study population included all smear positive TB patients registered in the Electronic TB Registry from Quarter 1 2007-Quarter 1 2009 in South Africa. Subdistricts were used as the unit of analysis, with each designated as either tracer (standard TB program plus tracer project) or non-tracer (standard TB program only). Mixed linear regression models were utilized to calculate the percent quarterly change in treatment outcomes and to compare changes in treatment outcomes from Quarter 1 2007 to Quarter 1 2009 between tracer and non-tracer subdistricts. RESULTS: For all provinces combined, the percent quarterly change decreased significantly for default treatment outcomes among tracer subdistricts (-0.031%; p<0.001) and increased significantly for successful treatment outcomes among tracer subdistricts (0.003; p=0.03). A significant decrease in the proportion of patient default was observed for all provinces combined over the time period comparing tracer and non-tracer subdistricts (p=0.02). Examination in stratified models revealed the results were not consistent across all provinces; significant differences were observed between tracer and non-tracer subdistricts over time in five of nine provinces for treatment default. CONCLUSIONS: Community mobilization of teams to trace TB patients that missed a clinic appointment or treatment dose may be an effective strategy to mitigate default rates and improve treatment outcomes. Additional information is necessary to identify best practices and elucidate discrepancies across provinces; these findings will help guide the NTP in optimizing the adoption of tracing activities for TB control.     

Viewing primary mental health care at a time of social transition in South Africa.

As South Africa shifts from a social structure based on the principles of apartheid to a democratic society, social policies must be developed that are consonant with the ideals of the "new" society. These must, however, take into account the current realities of the South African context. This article suggests that the application of the principles of primary mental health care is the approach most likely to meet mental health needs in the future South Africa, but that difficulties are likely to arise in the transition to this approach. These difficulties must be identified and dealt with. The authors discuss the problems in providing competent curative care to all and in shifting emphasis to prevention and promotion in mental health care. The discussion covers both practical and political complications. The authors conclude that though the process to primary mental health care will be a long one, the problems are unlikely to be insurmountable.     

Quality of life and burnout among public high school and primary school teachers in Southern Brazil

In order to investigate quality of life among public schoolteachers in relation to socio-demographic characteristics and work conditions, a cross-sectional study was conducted in a sample of 601 primary and secondary teachers from the State and Municipal public school system in the urban area of Pelotas, Rio Grande do Sul State, Brazil. The study analyzed the following domains from the WHOQOL-BREF scale: physical health, psychological health, social relationships, and environment. The mean indices were: 69.2 (SD = 16.8) for physical health, 70.6 (SD = 14.0) for psychological health, 72.5 (SD = 17.3) for social relationships, and 60.7 (SD = 14.0) for environment. Age, time in the teaching career, and total number of students were not significantly associated with quality of life. Teachers in municipal schools scored higher than their counterparts in the State public schools in the physical health domain (p = 0.026). Men scored higher than women in the physical and psychological health domains. Higher family income was associated with better quality of life. Higher classroom workload was associated with better scores in the physical health and environment domains.     

Primary health services at district level in South Africa: a critique of the primary health care approach

Background

The rhetoric of primary health care philosophy in the district health system is widely cited as a fundamental component of the health transformation process in post-apartheid South Africa. Despite South Africa??s progress and attempts at implementing primary health care, various factors still limit its success.

Discussion

Inconsistencies and poor understanding of primary care and primary health care raises unrealistic expectations in service delivery and health outcomes, and blame is apportioned when expectations are not met. It is important for all health practitioners to consider the contextual influences on health and ill-health and to recognise the role of the underlying determinants of ill-health, namely, social, economic and environmental influences. The primary health care approach provides a strong framework for this delivery but it is not widely applied. There is a need for renewed political and policy commitments toward quality primary health care delivery, re-orientation of health care workers, integration of primary health care activities into other community-based development, improved management skills and effective coordination at all levels of the health system. There should also be optimal capacity building, and skills development in problem-solving, communication, networking and community participation.

Summary

A well-functioning district health system is required for the re-engineering of primary health care. This strategy requires a strong leadership, a strengthening of the current district heath system and a greater emphasis on health promotion, prevention, and community participation and empowerment.     

初治涂阳肺结核患者细胞因子变化及生命质量分析

目的 了解初治涂阳肺结核患者的细胞因子变化和生命质量情况,分析其影响因素,为确定肺结核综合防治方案提供参考依据。方法 整群抽取浙江省台州市第一人民医院和温岭市结核病防治所2012年6月-2014年5月收治的196例初治涂阳肺结核患者,检测抗结核治疗前和治疗后2个月干扰素γ、白介素2、白介素10和白介素18的水平,同时应用中文版健康调查简表(SF-36)评价其生命质量情况,并分析生命质量的影响因素。结果 肺结核患者治疗2个月后干扰素γ和白介素2水平分别为(97.3±40.5)和(54.1±19.3)ng/L,均高于治疗前的(43.2±17.3)和(36.3±13.9)ng/L,白介素10和白介素18水平分别为(82.3±29.4)和(130.9±50.3)ng/L,均低于治疗前的(116.2±44.7)和(243.0±86.8)ng/L(均P<0.05);治疗2个月后痰菌转阴患者的干扰素γ和白介素2水平分别为(109.8±35.4)和(58.1±18.7)ng/L,均高于痰菌未转阴患者的(50.4±16.3)和(39.0±13.3)ng/L,白介素10和白介素18水平分别为(77.3±24.2)和(107.6±33.6)ng/L,均低于痰菌未转阴患者的(102.4±32.9)和(221.3±69.2)ng/L(均P<0.05);肺结核患者SF-36量表生理功能、生理职能、躯体疼痛、总体健康、活力、社会功能、情感职能、精神健康维度得分和生命质量总分分别为(70.14±23.07)、(45.32±21.69)、(67.42±18.26)、(61.28±26.34)、(49.32±16.85)、(57.64±12.46)、(64.71±11.31)、(52.83±20.47)和(512.25±132.57)分;多因素非条件logistic 回归分析结果显示,年龄>50岁、职业为农民、有债务负担和患慢性病的初治涂阳肺结核患者生命质量较低,文化程度初中及以上、年人均收入≥20 000元、有医保、治疗2个月后痰菌转阴和治疗3个月后病灶吸收的初治涂阳肺结核患者生命质量较高。结论 初治涂阳肺结核患者抗结核治疗后细胞因子水平增高,但生命质量较低;年龄、文化程度、职业、年人均收入、有无医保、有无债务负担、是否患慢性病、治疗后痰菌是否转阴及病灶是否吸收是其生命质量的主要影响因素。