Private sector tuberculosis care quality during the COVID-19 pandemic: A repeated cross-sectional standardized patients study of adherence to national TB guidelines in urban Nigeria (preprint)

Only a third of TB cases in Nigeria in 2020 were diagnosed and notified, in part due to low detection and underreporting from the private health sector. Using a standardized patient (SP) survey approach, we assessed how management of presumptive TB in the private sector aligns with national guidelines and whether this differed from a study conducted before the start of the COVID-19 pandemic. Thirteen standardized patients presented a presumptive TB case to 511 private providers in urban areas of Lagos and Kano states in May and June 2021. Private provider case management was compared with national guidelines divided into three main steps: SP questioned about cough duration; sputum collection attempted for TB testing; and non-prescription of anti-TB medications, antibiotics, and steroids. SP visits conducted in May-June 2021 were directly compared to SP visits conducted in the same areas in June-July 2019. Overall, only 145 of 511 (28%, 95% CI: 24.5-32.5%) interactions were correctly managed according to Nigerian guidelines, as few providers completed all three necessary steps. Providers in 71% of visits asked about cough duration (362 of 511, 95% CI: 66.7-74.7%), 35% tested or recommended a sputum test (181 of 511, 95% CI: 31.3-39.8%), and 79% avoided prescribing or dispensing unnecessary medications (406 of 511, 95% CI: 75.6-82.8%). COVID-19 related questions were asked in only 2.4% (12 of 511, 95% CI: 1.3-4.2%) of visits. During the COVID-19 pandemic, few providers completed all steps of the national guidelines. Providers performed better on individual steps, particularly asking about symptoms and avoiding prescription of harmful medications. Comparing visits conducted before and during the COVID-19 pandemic showed that COVID-19 did not significantly change the quality of TB care. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LILess than half of new TB cases in Nigeria are diagnosed and notified. As most initial health care seeking for TB in Nigeria occurs in the private sector, increasing the quality of TB care in the private sector is of great importance. C_LIO_LICOVID-19 may have put further stressors on TB care quality due to changes in care seeking behavior, stigma against COVID-19, and disproportionate attention at the health system level on pandemic control. C_LIO_LIThis study explored whether private providers practices are in alignment with national standards for TB screening in Nigeria, how these practices have changed following the onset of the COVID-19 pandemic, and what factors are associated with providers that deliver clinically correct TB screening services. C_LI What this study addsO_LIFewer than one-third of the SP visits conducted in this study were correctly managed according to the Nigerian National TB and Leprosy Control Program guidelines. C_LIO_LIClinical correctness of TB care in the private sector of urban Nigeria has not been majorly affected by COVID-19 according to our study results. C_LIO_LIOur results indicate that very little observed attention was paid to COVID-19 in this sample of private facilities. C_LI How this study might affect research, practice or policyO_LIIncreased efforts to engage and support private providers, and implementing solutions such as working with drug shop proprietors to make referring for testing a standard part of their practice may help reduce the testing bottleneck at drug shops. C_LIO_LIAlthough Nigeria has maintained pre-pandemic levels of TB notification, it is important to establish high-quality screening by all providers to find the missing patients with TB and close the gap in TB notification. C_LI

Individual healthcare-seeking pathways for tuberculosis in Nigeria private sector during the COVID-19 pandemic (preprint)

Background: Pre-COVID-19, individuals with TB in Nigeria were often underdiagnosed and untreated. Care for TB was mostly in the public sector while only 15% of new cases in 2019 were from the private sector. Reports highlighted challenges in accessing care in the private sector, which accounted for 67% of all initial care-seeking. Our study examined patients health seeking pathways for TB in Nigeria private sector, and explored any changes to care pathways during COVID, based on patients perspectives. Design/Methods: We conducted 180 cross-sectional surveys and 20 in-depth interviews with individuals having chest symptoms attending 18 high volume private clinics and hospitals in Kano and Lagos States. Questions focused on sociodemographic characteristics, health-seeking behavior and pathways to care during the COVID-19 periods. All surveys and interviews were conducted in May 2021. Results: Most participants were male (n=111, 62%), with average age of 37. Half (n=96, 53.4%) sought healthcare within a week of symptoms, while few (n=20, 11.1%) waited over 2 months. TB positive individuals had more health-seeking delays, and TB negative had more provider delays. On average, participants visited 2 providers in Kano and 1.69 in Lagos, with 61 (75%) in Kano and 48 (59%) in Lagos visiting other providers before the recruitment facility. Private providers were the initial encounters for most participants (n=60 or 66.7% in Kano, n-83 or 92.3% in Lagos). Most respondents (164 or 91%) experienced short-lived pandemic-related restrictions, particularly during the lockdowns, affecting access to transportation, and closed facilities. Conclusions: This study showed a few challenges in accessing TB healthcare in Nigeria, necessitating continued investment in healthcare infrastructure and resources, particularly in the private sector. Understanding the different care pathways and delays in care provides opportunities for targeted interventions to improve deployment of services closer to where patients first seek care.