Use of indicators of standards of care to improve tuberculosis program management in Ethiopia.

BACKGROUND: Systematic monitoring of health programs and on-site mentoring of health workers are essential for the success of health care. This operations research was designed to measure the effectiveness of a new mentorship and supervisory tool for supervisors. METHODS: In 2011 the Help Ethiopia Address the Low TB Performance (HEAL TB) Project used WHO or national TB indicators as standards of care (SOC) for baseline assessment, progress monitoring, gap identification, assessment of health workers' capacity-building needs, and data quality assurance. Cut-off points were selected for poor, average, and best performers for each indicator. In this analysis we present results from 10 zones (of 28) in which 1,165 health facilities were supported from 2011 through 2015. Other zones were excluded from the analysis because they entered the project later. The data were collected by trained mentors/supervisors and entered into Microsoft Excel. We used rates and ratios to show the impact of the intervention. RESULTS: The improvement in the median composite score of 13 selected major indicators (out of 22) over four years was significant (p = 0.000). The proportion of health facilities with 100% data accuracy for all forms of TB was 55.1% at baseline and reached 96.5%. In terms of program performance, the TB cure rate improved from 71% to 91.1%, while the treatment success rate increased from 88% to 95.3%. In the laboratory area, where there was previously no external quality assurance (EQA) for sputum microscopy, 1,165 health facilities now have quarterly EQA, and 96.1% of the facilities achieved a ≥ 95% concordance rate in blinded rechecking. CONCLUSION: The SOC approach for supervision was effective for measuring progress, enhancing quality of services, identifying capacity needs, and serving as a mentorship and an operational research tool.

Uptake of Isoniazid Preventive Therapy among Under-Five Children: TB Contact Investigation as an Entry Point.

A child's risk of developing tuberculosis (TB) can be reduced by nearly 60% with administration of 6 months course of isoniazid preventive therapy (IPT). However, uptake of IPT by national TB programs is low, and IPT delivery is a challenge in many resource-limited high TB-burden settings. Routinely collected program data was analyzed to determine the coverage and outcome of implementation of IPT for eligible under-five year old children in 28 health facilities in two regions of Ethiopia. A total of 504 index smear-positive pulmonary TB (SS+) cases were reported between October 2013 and June 2014 in the 28 health facilities. There were 282 under-five children registered as household contacts of these SS+ TB index cases, accounting for 17.9% of all household contacts. Of these, 237 (84%) were screened for TB symptoms, and presumptive TB was identified in 16 (6.8%) children. TB was confirmed in 5 children, producing an overall yield of 2.11% (95% confidence interval, 0.76-4.08%). Of 221 children eligible for IPT, 64.3% (142) received IPT, 80.3% (114) of whom successfully completed six months of therapy. No child developed active TB while on IPT. Contact screening is a good entry point for delivery of IPT to at risk children and should be routine practice as recommended by the WHO despite the implementation challenges.

Predictors of loss to follow-up in antiretroviral treatment for adult patients in the Oromia region, Ethiopia.

PURPOSE: It is known that antiretroviral treatment (ART) reduces mortality from acquired immunodeficiency syndrome related causes. Patient's lost to follow-up (LTFU) in this treatment poses a paramount problem to the public and health care services. Information on predictors of loss to follow-up is scarce in this study area and similar settings. Therefore, this study aimed at identifying correlates of loss to follow-up in ART among adult patients in the Oromia region of Ethiopia. METHODS: A case-control study was conducted between February 2015 and April 2015 using medical records. The stratified sampling technique was used to select health facilities. The number of patient records to be included in the study was proportionally allocated to each stratum based on their patient proportion in the regional data. Specific health facilities from which to include the records were randomly selected from a list of the health facilities per stratum. All adult patient records registered as LTFU (416) in the selected health facilities during the 12-month period prior to the data collection date, and 832 patients with good adherence to ART were included. Data were double-entered into Epi Info 7 and analyzed using SPSS 20. Descriptive statistics and binary logistic regression were used to report the results. Qualitative data were thematically analyzed using open code computer software. RESULTS: Age 15-24 years (adjusted odds ratio [AOR], 19.82 95% CI: 6.80, 57.73); day laborers (AOR, 5.36; 95% confidence interval [CI]: 3.23, 8.89), rural residents (AOR, 2.35; 95% CI: 1.45, 3.89), World Health Organization clinical stage IV (AOR, 2.29; 95% CI: 1.45, 3.62), baseline CD4 <350 cells/mL (AOR, 2.06; 95% CI: 1.36, 3.13), suboptimal adherence to ART (AOR, 7.42; 95% CI: 1.87, 29.41), were factors which increased the risk of loss to follow-up in ART. CONCLUSION: Multiple risk factors, both socioeconomic and clinical, were associated with loss to follow-up. Attention is required to address these factors during patient preparation for the treatment and follow-up counseling by practitioners. We recommend that other studies identify what happened to the patients registered as LTFU as the current study could not address this issue.

The synergy between TB and HIV co-infection on perceived stigma in Ethiopia.

BACKGROUND: The synergy between tuberculosis (TB) and human immunodeficiency virus (HIV) co-infection on perceived stigma is not well studied. The objective of this study was to assess the effect of TB/HIV co-infection on perceived stigma in selected hospitals of Oromiya region, Ethiopia. A cross sectional study was conducted from February to April, 2009 in Adama, Nekemet and Jimma Specialized hospitals. Data were collected by trained HIV counselors. A structured questionnaire which consisted of socio-demographic variables, clinical information, perceived stigma, and depression was used to collect the data FINDINGS: A total of 591 participants were included in the study of whom 124 (20.9%) were co-infected with TB/HIV. The stigma items were highly reliable (Cronbach's alpha = 0.93) and had strong inter dimension correlation. Respondents who were co-infected with TB and HIV were more likely to have perceived stigma compared to non-co-infected HIV patients, [OR = 1.4, (95% CI: 1.2, 2.0)]. Non-literate individuals [OR = 1.9, (95% CI: 1.2, 3.0)] and females [OR = 1.6, (95% CI: 1.2, 2.3)] had also more perceived stigma. CONCLUSIONS: TB/HIV co-infected patients, non-literate individuals and females were more likely to have high perceived stigma. Behavioral Change Communication should focus on these segments of the population to rectify the high perceived stigma.

Tuberculosis and HIV co-infection: its impact on quality of life.

BACKGROUND: Very little is known about the quality of life of tuberculosis (TB) and HIV co-infected patients. In this study in Ethiopia, we compared the quality of life HIV positive patients with and without TB. METHODS: A cross sectional study was conducted from February to April, 2009 in selected hospitals in Oromiya Regional state, Ethiopia. The study population consisted of 467 HIV patients and 124 TB/HIV co-infected patients. Data on quality of life was collected by trained nurses through face to face interviews using the short Amharic version of the World Health Organization Quality of Life Instrument for HIV clients (WHOQOL HIV). Depression was assessed using a validated version of the Kessler scale. Data was collected by trained nurses and analyzed using SPSS 15.0 statistical software. RESULTS: TB/HIV co-infected patients had a lower quality of life in all domains as compared to HIV infected patients without active TB. Depression, having a source of income and family support were strongly associated with most of the Quality of life domains. In co-infected patients, individuals who had depression were 8.8 times more likely to have poor physical health as compared to individuals who had no depression, OR = 8.8(95%CI: 3.2, 23). Self-stigma was associated with a poor quality of life in the psychological domain. CONCLUSION: The TB control program should design strategies to improve the quality of life of TB/HIV co-infected patients. Depression and self-stigma should be targeted for intervention to improve the quality of life of patients.