Barriers and facilitators to bidirectional screening of TB-DM in Ghana: Healthcare workers’ perspectives

Abstract

Background The tuberculosis (TB) and diabetes mellitus (DM) co-epidemic continues to increase globally. Low-and middle-income countries bear the highest burden of co-epidemic, and Ghana is no exception. In 2011, the World Health Organisation (WHO) responded to this global challenge by launching a collaborative framework with a view to guide countries in implementing their DM and TB care, prevention and control plans. Subsequently, several countries, including Ghana, adopted this framework and began implementing bidirectional screening of TB and DM patients. Almost a decade later since the launch of the framework, the implementation of bidirectional screening in Ghana has not been subjected to empirical research. This study explored the barriers and facilitators to bidirectional screening through the lenses of the implementing healthcare workers. Methods This was an exploratory qualitative study conducted in three public health facilities offering both TB and DM services in Northern Ghana. In-depth interviews, document review and observations, were used to generate data. In total twenty-three healthcare workers (doctors, nurses, prescriber, health managers and TB task-shifting officers delivering care in TB and DM clinics) were interviewed, using semi-structured interview guides. The interview questions solicited information on the screening process, including knowledge of the collaborative framework, comorbidity, collaboration and workload. Results Six themes emerged from the analysis, of which two (Increase in staff capacity, and Institutionalisation of bidirectional screening) were facilitators, and four (Delays in screening, Fear and stigmatization of TB, Poor collaboration between TB and DM units, and Skewed funding for screening) were barriers.

Acceptability and feasibility of tuberculosis and diabetes mellitus bidirectional screening and joint treatment services in Malawi: a cross-sectional study and a policy document review

“…Furthermore, the study reported that stigma due to TB disease, weak collaborative working culture among TB and DM clinics and financial challenges were among the barriers identified to be affecting implementation of effective integration of healthcare services. 48 On the other hand, a cross-sectional study that was conducted in Uganda 43 found that TB screening for DM in routine care was feasible, however, political will and programming issues were to be improved.…”

“…Therefore, varying situations and conditions at each setting should be considered before implementing an integrated approach. For instance, an exploratory study that was conducted in Ghana48 found that staff development and establishment of bidirectional screening services can contribute to facilitating the implementation of integrated care for TB and DM. Furthermore, the study reported that stigma due to TB disease, weak collaborative working culture among TB and DM clinics and financial challenges were among the barriers identified to be affecting implementation of effective integration of healthcare services 48.…”

Integrated Management of Diabetes and Tuberculosis in Rural India – Results From a Pilot Study

“…There is need to institutionalize bi-directional screening of patients with TB and DM and screen individuals for other co-morbidities such as hypertension which would impact the outcomes. WHO's TB-DM collaborative framework and India's TB strategy recommends screening of TB and DM patients ( 25 ). The framework also encourages implementation research to contextualize to local health systems.…”

The co-management of tuberculosis-diabetes co-morbidities in Indonesia under the National Tuberculosis Control Program: results from a cross-sectional study from 2017 to 2019

“…Coordination between TB and NCD control programs needs to be improved to strengthen TB-DM co-management. Though the WHO has also called for the establishment of a formal collaboration between the NCD prevention and TB control programs in TB-DM comanagement [12], TB and DM service integration has been especially challenging as in the past they have been individual vertical programs delivered under different divisions of the health department with little collaboration [41][42][43][44]. In Indonesia, only NTP issued guidelines on TB-DM co-management while the NCD department has not.…”