Background: The human resources for health crisis in rural Eswatini led to a novel community-based multidrug-resistant tuberculosis (MDR-TB) treatment strategy based on task-shifting, that is delegation of directly observed treatment (DOT) and administration of MDR-TB injections, traditionally restricted to professional nurses, to lay community treatment supporters (CTSs).Aim: This study assessed the level of patient satisfaction with receiving community-based MDR-TB care from a CTS.Setting: The study was conducted at three MDR-TB-treating facilities in the mostly rural Shiselweni region.Methods: A cross-sectional survey of a purposive sample of 78 patients receiving DOT and intramuscular MDR-TB injections from CTSs was carried out in 2017. Descriptive statistics and regressions were calculated.Results: A high overall general patient satisfaction score for receiving community-based MDR-TB care from a CTS was observed. Adherence counselling, confidentiality, provider selection and treatment costs significantly (p 0.05) influenced satisfaction. A large majority (n = 62; 79.5%) of patients indicated that they would likely recommend their significant others to receive MDR-TB care from a CTS. Respondents identified the need to provide CTSs with adequate training, regular supervision and sufficient incentives and also to broaden the scope of their services.Conclusion: This study observed that task-shifting of DOT and MDR-TB injection administration to CTSs was supported from a patient perspective. However, adherence counselling, confidentiality, provider selection and treatment costs should be taken into account in community-based MDR-TB care programming. Further to the patients, community-based tuberculosis care could be enhanced by improving CTSs’ training, supervision and incentives, and broadening the scope of their services.
Background Eswatini is facing a critical shortage of human resources for health (HRH) and limited access to multidrug-resistant tuberculosis (MDR-TB) treatment in rural areas. This study assessed multiple stakeholders’ perceptions of task-shifting directly observed treatment (DOT) supervision and administration of intramuscular MDR-TB injections to lay health workers (LHWs). Methods A mixed methods study comprising a cross-sectional survey using a semi-structured questionnaire with community treatment supporters (CTSs) and a focus group discussion with key stakeholders including representatives from the Eswatini Ministry of Health (MOH), donor organisations, professional regulatory institutions, nursing academia, civil society and healthcare providers was conducted in May 2017. Descriptive statistics, thematic content analysis and data triangulation aided in the interpretation of results. Results A large majority of CTSs (n = 78; 95.1%) were female and 33 (40.2%) were older than 50 years. Most (n = 7; 70.0%) key stakeholders had over 10 years of work experience in policy-making, advocacy in the fields of HRH or day-to-day practice in MDR-TB management. Task-shifting of MDR-TB injection administration was implemented without national policy guidance and regulation. Stakeholders viewed the strategy to be driven by the prevailing shortage of professional frontline HRH and limited access to MDR-TB treatment. Task-shifting was perceived to improve medication adherence, and reduce stigma and transport-related MDR-TB treatment access barriers. Frontline healthcare workers and implementing donor partners fully supported task-shifting. Policy-makers and other stakeholders accepted task-shifting conditionally due to fears of poor standards of care related to perceived incompetence of CTSs. Appropriate compensation, adequate training and supervision, and non-financial incentives were suggested to retain CTSs. A holistic task-shifting policy and collaboration between the MOH, academia and nursing council in regulating the practice were recommended. Conclusions Stakeholders generally accepted the delegation of DOT supervision and administration of intramuscular MDR-TB injections to LHWs as a strategy to increase access to treatment, albeit with some apprehension. Findings from this study stress that task-shifting is not a panacea for HRH shortages, but a short-term solution that must form part of an overall simultaneous strategy to train, attract and retain adequate numbers of professional healthcare workers in Eswatini. To address some of the apprehension and ambivalence about expanding access to MDR-TB services through task-shifting, attention should be paid to important aspects such as competence-based training, certification and accreditation, adequate supportive on-the-job supervision, recognition, compensation, and expediting policy and regulatory support for LHWs.
Background This study assessed knowledge, attitudes and practices (KAP) of lay community treatment supporters (CTSs) delegated with directly observed treatment (DOT) supervision and administration of intramuscular multidrug-resistant tuberculosis (MDR-TB) injections in the Shiselweni region in Eswatini. Methodology A cross-sectional survey among a purposive sample of 82 CTSs providing DOT and administering injections to MDR-TB patients was conducted in May 2017. Observations in the patients’ homes were undertaken to verify CTSs’ self-reported community-based MDR-TB management practices. Results Out of 82 respondents, 78 (95.1%) were female and half (n = 41; 50.0%) had primary education or lower. Over one-tenth (n = 12; 14.6%) had not attended a MDR-TB training workshop, but were administering injections. The overall KAP scores were satisfactory. Good self-reported community-based MDR-TB practices were largely verified through observation. However, substantial proportions of respondents incorrectly defined MDR-TB, were unaware of the treatment regimen, stigmatised patients, and underreported needlestick injuries. There was no statistically significant association between duration administering intramuscular injections, MDR-TB training, knowledge and attitudes, and good community-based MDR-TB management practices. Conclusions The gaps in the current KAP of CTSs in this setting raise questions about the timing, adequacy, design and content of community-based MDR-TB management training. Nonetheless, with appropriate training, lay CTSs in this region can be an option to complement an overstretched professional health workforce in providing DOT and MDR-TB injections at community level.
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