Fidelity of implementation of TB screening guidelines by health providers at selected HIV clinics in Ghana

Abstract

Introduction Tuberculosis screening of people living with human immunodeficiency virus is an intervention recommended by the WHO to control the dual epidemic of TB and HIV. The extent to which the intervention is adhered to by the HIV healthcare providers (fidelity) determines the intervention’s effectiveness as measured by patient outcomes, but literature on fidelity is scarce. This study assessed provider implementation fidelity to national guidelines on TB screening at HIV clinics in Ghana. Methods It was a cross-sectional study that used structured questionnaires to gather data, involving 226 of 243 HIV healthcare providers in 27 HIV clinics across Ghana. The overall fidelity score comprised sixteen items with a maximum score of 48 grouped into three components of the screening intervention (TB diagnosis, TB awareness and TB symptoms questionnaire). Simple summation of item scores was done to determine fidelity score per provider. In this paper, we define the level of fidelity as low if the scores were below the median score and were otherwise categorized as high. Background factors potentially associated with implementation fidelity level were assessed using cluster-based logistic regression. Odds ratio with 95% confidence interval (CI) was used as the measure of association. Results Of the 226 healthcare providers interviewed, 60% (135) were females with a mean age of 34.5 years (SD = 8.3). Most of them were clinicians [63% (142)] and had post-secondary non-tertiary education [62% (141)]. Overall, 53% (119) of the healthcare providers were categorized to have implemented the intervention with high fidelity. Also, 56% (126), 53% (120), and 59% (134) of the providers implemented the TB diagnosis, TB awareness and TB symptoms questionnaire components respectively with high fidelity. After adjusting for cluster effect, female providers (AOR = 2.36, 95%CI: 1.09–5.10, p = <0.029), those with tertiary education (AOR = 4.31, 95%CI: 2.12–9.10, p = 0.040), and clinicians (AOR = 1.78, 95%CI: 1.07–3.50, p = 0.045) were more likely to adhere to the guidelines compared to their counterparts. Conclusion The number of providers with fidelity scores above the median was marginally greater (6%) than the number with fidelity score below the median. Similarly, for each of the components, the number of providers with fidelity scores higher than the median was marginally higher. This could explain the existing fluctuations in the intervention outcomes in Ghana. We found gender, profession and education were associated with provider implementation fidelity. To improve fidelity level among HIV healthcare providers, and realize the aims of the TB screening intervention among PLHIV in Ghana, further training on implementing all components of the intervention is critical.

Factors influencing the implementation of TB screening among PLHIV in selected HIV clinics in Ghana: a qualitative study

“…The national TB programme’s plan was to initiate IPT among PLHIV with a negative TB screen at HIV clinics in Ghana. Therefore, 27 district hospitals were earmarked to start the implementation, after which it would be scaled up to other district hospitals [ 19 ] as described and published elsewhere [ 47 , 48 ]. Therefore, the main study was conducted in the 27 district hospitals across all the regions.…”

Weighted fidelity of delivery of an intervention in the health facility: a case of TB screening among PLHIV in selected hospitals in Ghana

“…This is referred to as implementation delity or adherence to the delivery [6][7][8]. As discussed earlier, some of these studies assessed delity of delivery from either the health workers' perspective [9] or the facility (managers') perspective [10].…”

“…The intervention consisted of standard components delivered by the facility managers and components provided to all HIV clients by the HIV health worker. Details of the intervention components for the managers are reported in the facility level delity paper [10], while that of the HIV care providers are reported in the provider level delity paper [9].…”

“…Details of the study area are published elsewhere [9,10], but brie y, it was conducted in 27 district hospitals with functioning HIV clinics in Ghana. These hospitals are located across the length and breadth of the country.…”

Implementation fidelity to HIV assisted partner services (aPS) during scale-up in western Kenya: a convergent mixed methods study

“…Although achieving high fidelity within controlled research settings might be relatively easy due to stringent monitoring and evaluation, this can be quite challenging in real-world settings [ 3 ]. Numerous contextual factors outside the control of practitioners such as limited resources to support hiring, training, adoption, and scale-up, jeopardize implementation fidelity as well as intended outcomes [ 3 , 4 ].…”