Implementation of the Xpert MTB/RIF assay for tuberculosis in Mongolia: a qualitative exploration of barriers and enablers

Abstract

ObjectiveThe aim of our study was to identify barriers and enablers to implementation of the Xpert MTB/RIF test within Mongolia’s National Tuberculosis Program.MethodsTwenty-foursemi-structured interviews were conducted between June and September 2015 with laboratory staff and tuberculosis physicians in Mongolia’s capital Ulaanbaatar and regional towns where Xpert MTB/RIF testing had been implemented. Interviews were recorded, transcribed, translated and analysed thematically using NVIVO qualitative analysis software.ResultsEight laboratory staff (five from the National Tuberculosis Reference Laboratory in Ulaanbaatar and three from provincial laboratories) and sixteen tuberculosis physicians (five from the Mongolian National Center for Communicable Diseases in Ulaanbaatar, four from district tuberculosis clinics in Ulaanbaatar and seven from provincial tuberculosis clinics) were interviewed. Major barriers to Xpert MTB/RIF implementation identified were: lack of awareness of program guidelines; inadequate staffing arrangements; problems with cartridge supply management; lack of local repair options for the Xpert machines; lack of regular formal training; paper based system; delayed treatment initiation due to consensus meeting and poor sample quality. Enablers to Xpert MTB/RIF implementation included availability of guidelines in the local language; provision of extra laboratory staff, shift working arrangements and additional modules; capacity for troubleshooting internally; access to experts; opportunities for peer learning; common understanding of diagnostic algorithms and decentralised testing.ConclusionOur study identified a number of barriers and enablers to implementation of Xpert MTB/RIF in the Mongolian National Tuberculosis Program. Lessons learned from this study can help to facilitate implementation of Xpert MTB/RIF in other Mongolian locations as well as other low-and middle-income countries.

Through service providers’ eyes: health systems factors affecting implementation of tuberculosis control in Enugu State, South-Eastern Nigeria

“…Social stigma and concern for contracting TB meant that health workers refuse deployment to and participation in TB control programmes. Also, the findings of weak laboratory capacity due to lack of space, damaged microscopes, attrition of laboratory staff and operational challenges of GeneXpert, are like evidence from previous studies [5,11,14,22,23,26,27]. Equally, poor involvement of community volunteers and patent medicine vendors due to withdrawal of financial incentives hindered TB service delivery.…”

“…Shortages of TB drug [7,22] and unavailability of laboratory supplies and equipment hinder TB service delivery [7,11,22]. Poor adherence to GeneXpert algorithm, interrupted supply of cartridges, lack of replacement of damaged modules, poor maintenance, and poor recording and reporting limit usefulness of GeneXpert in TB diagnosis [14,26,27]. Poor adherence to national guidelines [11,22,23]; dilapidated infrastructure [5,12,23] weak TB/HIV integration [10,12,14,24,28]; lack of public-private mix [10,12,23] and poor integration into general health services hinder effective TB service delivery [5,29,30].…”

The implementation of Xpert MTB/RIF assay for diagnosis of tuberculosis in Nepal: A mixed-methods analysis

“…In our study, 11 of 21 centres had test failure rates of more than 7% and 2 out of 21 centres had high rates of indeterminate results. Reasons for this were unclear but may indicate poor sputum collection technique or environmental impact on cartridges such as the high temperature of the laboratory which was also found in a study from Mongolia [ 24 ]. The overall average test failure rates of 7.5% was less than that reported (10.7%) in one research conducted in nine countries, including Nepal [ 21 ].…”

Study protocol: a cluster randomized trial to evaluate the effectiveness and implementation of onsite GeneXpert testing at community health centers in Uganda (XPEL-TB)

“…To increase access to Xpert testing, many high-burden countries have established specimen referral networks linking lower-level health facilities (spokes) to health facilities equipped with GeneXpert devices (hubs) [5][6][7][8]. However, studies have documented persistent challenges to the TB diagnostic evaluation process, including low utilization of Xpert, delays between sputum collection and return of Xpert results, and high rates of pre-treatment loss to follow-up for Xpertpositive patients [9][10][11].…”