Top

BMC Health Services Research

Published in:

Open Access 01-06-2015 | Research article

Pathways to multidrug-resistant tuberculosis diagnosis and treatment initiation: a qualitative comparison of patients’ experiences in the era of rapid molecular diagnostic tests

Authors: Pren Naidoo, Margaret van Niekerk, Elizabeth du Toit, Nulda Beyers, Natalie Leon

Published in: BMC Health Services Research | Issue 1/2015

Abstract

Background

Although new molecular diagnostic tests such as GenoType MTBDRplus and Xpert® MTB/RIF have reduced multidrug-resistant tuberculosis (MDR-TB) treatment initiation times, patients’ experiences of diagnosis and treatment initiation are not known. This study aimed to explore and compare MDR-TB patients’ experiences of their diagnostic and treatment initiation pathway in GenoType MTBDRplus and Xpert® MTB/RIF-based diagnostic algorithms.

Methods

The study was undertaken in Cape Town, South Africa where primary health-care services provided free TB diagnosis and treatment. A smear, culture and GenoType MTBDRplus diagnostic algorithm was used in 2010, with Xpert® MTB/RIF phased in from 2011–2013. Participants diagnosed in each algorithm at four facilities were purposively sampled, stratifying by age, gender and MDR-TB risk profiles. We conducted in-depth qualitative interviews using a semi-structured interview guide. Through constant comparative analysis we induced common and divergent themes related to symptom recognition, health-care access, testing for MDR-TB and treatment initiation within and between groups. Data were triangulated with clinical information and health visit data from a structured questionnaire.

Results

We identified both enablers and barriers to early MDR-TB diagnosis and treatment. Half the patients had previously been treated for TB; most recognised recurring symptoms and reported early health-seeking. Those who attributed symptoms to other causes delayed health-seeking. Perceptions of poor public sector services were prevalent and may have contributed both to deferred health-seeking and to patient’s use of the private sector, contributing to delays. However, once on treatment, most patients expressed satisfaction with public sector care. Two patients in the Xpert® MTB/RIF-based algorithm exemplified its potential to reduce delays, commencing MDR-TB treatment within a week of their first health contact. However, most patients in both algorithms experienced substantial delays. Avoidable health system delays resulted from providers not testing for TB at initial health contact, non-adherence to testing algorithms, results not being available and failure to promptly recall patients with positive results.

Conclusion

Whilst the introduction of rapid tests such as Xpert® MTB/RIF can expedite MDR-TB diagnosis and treatment initiation, the full benefits are unlikely to be realised without reducing delays in health-seeking and addressing the structural barriers present in the health-care system.

World Health Organisation. Global Tuberculosis Report 2013. © World Health Organization 2013. WHO/HTM/TB/2013.11. Available from http://apps.who.int/iris/bitstream/10665/91355/1/9789241564656_eng.pdf.

Dowdy DW, Chaisson RE, Maartens G, Corbett EL, Dorman SE. Impact of enhanced tuberculosis diagnosis in South Africa: a mathematical model of expanded culture and drug susceptibility testing. Proc Natl Acad Sci U S A. 2008;105:11293–8.CrossRefPubMedPubMedCentral

Dye C. Doomsday postponed? Preventing and reversing epidemics of drug-resistant tuberculosis. Nat Rev Microbiol. 2009;7:81–7.CrossRefPubMed

World Health Organisation. Molecular Line Probe Assays For Rapid Screening Of Patients At Risk Of Multidrug-Resistant Tuberculosis, Policy Statement. 2008. Available from http://www.who.int/tb/features_archive/policy_statement.pdf?ua=1.

World Health Organisation. Automated Real-Time Nucleic Acid Amplification Technology for Rapid and Simultaneous Detection of Tuberculosis and Rifampicin Resistance: Xpert MTB / RIF System. Policy Statement. 2011. © World Health Organization 2011. WHO/HTM/TB/2011.4. Available from http://apps.who.int/iris/bitstream/10665/44586/1/9789241501545_eng.pdf.

World Health Organisation. Molecular Line Probe Assays For Rapid Screening Of Patients At Risk Of Multidrug-Resistant Tuberculosis. Expert Group Report. 2008. Available from http://www.who.int/tb/features_archive/expert_group_report_june08.pdf.

Jacobson KR, Theron D, Kendall E, Franke MF, Barnard M, van Helden PD, et al. Implementation of genotype MTBDRplus reduces time to multidrug-resistant tuberculosis therapy initiation in South Africa. Clin Infect Dis. 2013;56:503–8.CrossRefPubMed

Naidoo P, du Toit E, Dunbar R, Lombard C, Caldwell J, Detjen A, et al. A Comparison of Multidrug-Resistant Tuberculosis Treatment Commencement Times in MDRTBPlus Line Probe Assay and Xpert® MTB/RIF-Based Algorithms in a Routine Operational Setting in Cape Town. PLoS One. 2014;9, e103328.CrossRefPubMedPubMedCentral

Dowdy DW, Cattamanchi A, Steingart KR, Pai M. Is scale-up worth it? Challenges in economic analysis of diagnostic tests for tuberculosis. PLoS Med. 2011;8, e1001063.CrossRefPubMedPubMedCentral

10.

Finnie RKC, Khoza LB, van den Borne B, Mabunda T, Abotchie P, Mullen PD. Factors associated with patient and health care system delay in diagnosis and treatment for TB in sub-Saharan African countries with high burdens of TB and HIV. Trop Med Int Health. 2011;16:394–411.CrossRefPubMed

11.

Mavhu W, Dauya E, Bandason T, Munyati S, Cowan FM, Hart G, et al. Chronic cough and its association with TB-HIV co-infection: factors affecting help-seeking behaviour in Harare, Zimbabwe. Trop Med Int Health. 2010;15:574–9.PubMedPubMedCentral

12.

Mochache LN, Nyamongo IK. Factors influencing tuberculosis management in rural south-west. Kenya. 2009;13:895–9.

13.

Skordis-Worrall J, Hanson K, Mills A. Confusion, caring and tuberculosis diagnostic delay in Cape Town. South Africa. 2010;14:171–80.

14.

Yimer S, Bjune G, Alene G. Diagnostic and treatment delay among pulmonary tuberculosis patients in Ethiopia: a cross sectional study. BMC Infect Dis. 2005;5:112. doi:10.1186/1471-2334-5-112. Available from: http://www.biomedcentral.com/1471-2334/5/112. Downloaded 30 April 2013.CrossRefPubMedPubMedCentral

15.

Godfrey-Faussett P, Kaunda H, Kamanga J, van Beers S, van Cleeff M, Kumwenda-Phiri R, et al. Why do patients with a cough delay seeking care at Lusaka urban health centres? A health systems research approach. Int J Tuberc Lung Dis. 2002;6:796–805.PubMed

16.

Cowan J, Greenberg Cowan J, Barnhart S, Demamu S, Fiseha D, Graham W, et al. A qualitative assessment of challenges to tuberculosis management and prevention in Northern Ethiopia. Int J Tuberc lung Dis. 2013;17:1071–5.CrossRefPubMedPubMedCentral

17.

Millen SJ, Uys PW, Hargrove J, van Helden PD, Williams BG. The effect of diagnostic delays on the drop-out rate and the total delay to diagnosis of tuberculosis. PLoS One. 2008;3(4):e1933. doi:10.1371/journal.pone.0001933. Downloaded 02 May 2013.CrossRefPubMedPubMedCentral

18.

Mann G, Squire SB, Bissell K, Eliseev P, Du Toit E, Hesseling A, et al. Beyond accuracy : creating a comprehensive evidence base for tuberculosis diagnostic tools. IJTLD. 2010;14:1518–24.

19.

Demissie M, Lindtjorn B, Berhane Y. Patient and health service delay in the diagnosis of pulmonary tuberculosis in Ethiopia. BMC Public Health 2002;2(1):23 Avaialble from http://www.biomedcentral.com/content/pdf/1471-2458-2-23.pdf.

20.

Lambert ML, Van der Stuyft P. Delays to tuberculosis treatment: shall we continue to blame the victim? Trop Med Int Health. 2005;10:945–6.CrossRefPubMed

21.

Storla DG, Yimer S, Bjune GA. A systematic review of delay in the diagnosis and treatment of tuberculosis. BMC Public Health. 2008;8:15. doi:10.1186/1471-2458-8-15. Available from http://www.biomedcentral.com/1471-2458/8/15. Downloaded 30 April 2013.CrossRefPubMedPubMedCentral

22.

Rajeswari R, Chandrasekaran V, Suhadev M, Sivasubramaniam S, Sudha G, Renu G. Factors associated with patient and health system delays in the diagnosis of tuberculosis in South India. Int J Tuberc Lung Dis. 2002;6:789–95.PubMed

23.

Kasse Y, Jasseh M, Corrah T, Donkor S, Antonnio M, Jallow A, et al. Health seeking behaviour, health system experience and tuberculosis case finding in Gambians with cough. BMC Public Health. 2006;6:143. doi:10.1186/1471-2458-6-143. Available from http://www.biomedcentral.com/1471-2458/6/143. Downloaded 27 August 2014.CrossRefPubMedPubMedCentral

24.

Luis SF, Kamp N, Mitchell EMH, Henriksen K, van Leth F. Health-seeking norms for tuberculosis symptoms in southern Angola: implications for behaviour change communications. Int J Tuberc Lung Dis. 2011;15:943–8.CrossRefPubMed

25.

Senbeto M, Tadesse S, Tadesse T, Melesse T. Appropriate health-seeking behavior and associated factors among people who had cough for at least two weeks in northwest Ethiopia: a population-based cross-sectional study. BMC Public Health. 2013;13:1222. Available from http://www.biomedcentral.com/1471-2458/13/1222. Downloaded 27 August 2014.CrossRefPubMedPubMedCentral

26.

Verver S, Warren RM, Beyers N, Richardson M, van der Spuy GD, Borgdorff MW, et al. Rate of reinfection tuberculosis after successful treatment is higher than rate of new tuberculosis. Am J Respir Crit Care Med. 2005;171:1430–5.CrossRefPubMed

27.

Glynn JR, Murray J, Bester A, Nelson G, Shearer S, Sonnenberg P. High rates of recurrence in HIV-infected and HIV-uninfected patients with tuberculosis. J Infect Dis. 2010;201:704–11.CrossRefPubMed

28.

Needham DM, Foster SD, Tomlinson G, Godfrey-Faussett P. Socio-economic, gender and health services factors affecting diagnostic delay for tuberculosis patients in urban Zambia. Trop Med Int Health. 2001;6:256–9.CrossRefPubMed

29.

Pronyk RM, Makhubele MB, Hargreaves JR, Tollman SM, Hausler HP. Assessing health seeking behaviour among tuberculosis patients in rural South Africa. Int J Tuberc Lung Dis. 2001;5:619–27.PubMed

30.

Fochsen G, Deshpande K, Diwan V, Mishra A, Diwan VK, Thorson A. Health care seeking among individuals with cough and tuberculosis: a population-based study from rural India. Int J Tuberc Lung Dis. 2006;10:995–1000.PubMed

31.

Hoa NP, Thorson A, Long NH, Diwan V. Knowledge of tuberculosis and associated health-seeking behaviour among rural Vietnamese adults with a cough for at least three weeks. Scand J Public Health. 2003;31:59–65.CrossRef

32.

Nathanson E, Nunn P, Uplekar M, Floyd K, Jaramillo E, Lönnroth K, et al. MDR Tuberculosis - Critical Steps for Prevention and Control. N Engl J Med. 2010;363:1050–8.CrossRefPubMed

33.

Pope C, Mays N. Qualitative Methods in Health Research. In Qual Res Heal Care. Blackwell Publishing Ltd; 2007; pp1–11.

34.

Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Soc Sci Med. 2009;68:2240–6.CrossRefPubMed

35.

Raviglione MC, Pio A. Evolution of WHO policies for tuberculosis control, 1948–2001. Lancet. 2002;359:775–80.CrossRefPubMed

36.

Zumla A, Cobelens F. Operational research and MDG tuberculosis control targets. Lancet Infect Dis. 2012;12:262–3.CrossRefPubMed

Title: Pathways to multidrug-resistant tuberculosis diagnosis and treatment initiation: a qualitative comparison of patients’ experiences in the era of rapid molecular diagnostic tests
Authors: Pren Naidoo
Margaret van Niekerk
Elizabeth du Toit
Nulda Beyers
Natalie Leon
Publication date: 01-06-2015
Publisher: BioMed Central
Published in: BMC Health Services Research / Issue 1/2015
Electronic ISSN: 1472-6963
DOI: https://doi.org/10.1186/s12913-015-1145-0

2024 ASCO Annual Meeting

Springer Medicine

Pathways to multidrug-resistant tuberculosis diagnosis and treatment initiation: a qualitative comparison of patients’ experiences in the era of rapid molecular diagnostic tests

Abstract

Background

Methods

Results

Conclusion

2024 ASCO Annual Meeting

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 1/2015

Roundtable discussion on the Third Global Symposium on Health Systems Research: why prioritise talk over aid in the midst of the Ebola crisis?

Exploring providers’ perspectives of a community based TB approach in Southern Ethiopia: implication for community based approaches

Adaptive coordination in surgical teams: an interview study

An in-depth assessment of India’s Mother and Child Tracking System (MCTS) in Rajasthan and Uttar Pradesh

Determinants of the intention to use e-Health by community dwelling older people

Shared decision making in designing new healthcare environments—time to begin improving quality