Perceptions of health care providers of multi-drug resistant tuberculosis shorter-course treatment regimen implementation in Harare, Zimbabwe

Tanda, Tuso Audrey
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Background Globally, TB remains a major public health concern with multi-drug resistant tuberculosis (MDR-TB) contributing substantially to the tuberculosis (TB) burden. Slow progress has been made over the years in global detection and enrolment of MDR-TB patients on treatment. The global Covid-19 pandemic negatively impacted access to TB services reducing the detection and enrolment of MDR-TB patients in 2020. Nine of the thirty countries with the highest burden of MDR-TB are in Europe. Accounting for the burden of MDR-TB in African countries remains a challenge, with only half of the African countries having conducted a drug resistance survey. Inappropriate regimens for MDR-TB patients enrolled on treatment remains a challenge in European and African countries. The World Health Organization (WHO) 2016 TB guidelines recommended the use of a standard regimen with a shorter duration of 9-12 months. In July 2018, the Zimbabwe National Tuberculosis Program (NTP) launched the implementation of the recommended standard shorter treatment regimen. There is a paucity of information on how health providers perceive the implementation of MDR-TB shorter-course treatment regimen in Harare, Zimbabwe. Objective The objective of this study was to explore the facilitators and barriers to implementation of the standardised shorter treatment regimen for MDR-TB from a health care providers’ (HCP) perspective in Harare, Zimbabwe. Methods The study was an in-depth qualitative study. Health care providers from public health facilities within Harare province were purposively sampled for in depth interviews. These were guided by an open-ended interview guide. The data collection was conducted between April and July 2021. The consolidated framework for implementation research (CFIR) guided the interview guide development, data collection and the data analysis process. Data were managed and stored using MAXQDA 2020. The framework approach was used for data analysis. Results Ten participants constituting doctors, nurses and environmental health officers participated in the study. Seven major themes emerged from the study guided by the CFIR domains and constructs. These salient themes were: 1) Health care provider perceptions of patient needs and preferences. 2) Health care provider perceptions of the shorter MDR-TB regimen. 3) Health care provider perceptions of the health service environment. 4) Health care provider perceptions of global and local policies and guidelines. 5) Health care provider perceptions of opportunities for information dissemination. 6) Health care provider description of the MDRTB shorter treatment regimen implementation process and, 7) Health care provider perceptions on collaborations and stakeholder engagements. Meeting patient needs, supporting the health care providers in the work environment, involvement of stakeholders, aligning implementation to global and local policies were perceived as facilitators. Major barriers identified were related to inadequate resources, failure to meet patient and health care provider needs. Conclusion Health care provider perceptions of implementation of the shorter treatment regimen for MDRTB were similar across all CFIR constructs in Harare health facilities. The implementation of the shorter regimen is influenced by several barriers and facilitators from all the five CFIR domains. Implementation of the shorter treatment regimen for MDR-TB requires strategies that go beyond the health facility. Developing an all-inclusive approach to implementing recommended treatment regimens may improve the outcomes for MDR-TB patients. Measures to mitigate the impact of Covid-19 on the MDR-TB program need to be swiftly adopted by the Zimbabwe National TB program.
A research report submitted in partial fulfilment of the requirements for the Degree of Master of Science in Epidemiology to the Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, 2022