Poor adherence to TB diagnosis guidelines among under-five children with severe acute malnutrition in central India: A missed window of opportunity?

Abstract

Background In India, under-five children with Severe Acute Malnutrition (SAM) are referred to Nutritional Rehabilitation Centers (NRCs). NRCs screen the causes of SAM including tuberculosis (TB). The national TB programme recommends upfront testing with a rapid molecular test if TB is suspected in children. Objective We estimated the yield of and adherence to the TB diagnostic guidelines (clinical assessment and assessment for microbiological confirmation) among under-five children with SAM admitted at NRCs (six in district Sagar and four in district Sheopur) of Madhya Pradesh, India in 2017. We also explored the challenges in screening from the health care providers’ perspective. Methods It was an explanatory mixed method study. The NRC records were reviewed This was followed by three key informant interviews and three focus group discussions among staff of NRC and TB programme. Manual descriptive thematic analysis was performed. Results Of 3230, a total of 2665(83%) children underwent Mantoux test, 2438(75%) underwent physical examination, 2277(70%) were asked about the symptoms suggestive of TB, 1220(38%) underwent chest radiograph and 485(15%) were asked for recent contact with TB. A total of 547(17%) underwent assessment for microbiological confirmation. Of 547, a total of 229 gastric aspirate specimens underwent rapid molecular test (24% positive) and 318 underwent sputum microscopy (44% positive). A total of 223 were diagnosed as TB (195 microbiologically and 28 clinically confirmed) and 209 were initiated on anti-TB treatment. The treatment outcome was favourable (cure or treatment completed) for 70(31%) and not recorded for 121(54%). The main perceived challenges in screening for TB were poor team skills, lack of diagnostic facilities and poor understanding of the guidelines due to inadequate training. Conclusion Though NRCs provided a unique window of opportunity for the screening and management of TB among under-five children with SAM, the utilization of this opportunity remained suboptimal.

A synthesis of qualitative evidence of barriers and facilitators in implementing guidelines for TB testing in healthcare settings

“…Eight studies were from lower-middle-income countries [ 9 , 31 , 36 , 37 , 40 , 41 , 43 , 46 ], five were from upper-middle-income countries [ 6 , 33 , 34 , 39 , 45 ], six were from high-income countries [ 7 , 8 , 32 , 38 , 47 , 48 ] and two were from low-income countries [ 35 , 42 ]. Four studies had representatives from a mix of countries with different income levels [ 5 , 29 , 30 , 44 ].…”

“…For providers of care, lack of confidence in TB tests, mistrust of the guidelines, fear of misusing tests, perceived difficulty in obtaining specimens and patients’ reaction guiding practice were barriers to implementing TB diagnostic guidelines [ 6 , 29 – 32 , 34 – 36 , 40 , 41 , 43 – 45 , 47 , 48 ]. Lack of confidence in TB test factors were perceived non-feasibility, low sensitivity of diagnostic tests and scepticism about test speed and reliability [ 6 , 29 – 32 , 34 – 36 , 40 , 41 , 43 – 45 , 47 , 48 ]. Providers deviated from guidelines/algorithms based on their perceptions of patient reactions to clinical decisions, for example, ordering X-rays against clinical policy to meet perceived expectations of the patient [ 29 ].…”

“…For providers of care, barriers to implementing TB diagnosis guidelines were poor awareness and understanding of guidelines/diagnostic algorithms, poor understanding of TB disease and challenges in sample collection, especially among children [ 6 – 8 , 31 , 34 , 36 , 37 , 39 – 41 , 43 , 44 , 47 , 48 ]. Adequate knowledge about the guidelines/diagnostic algorithms and disease promoted the implementation of TB diagnostic guidelines [ 5 , 6 , 36 , 37 , 40 , 43 , 45 , 46 , 48 ].…”

“…Barriers related to guideline quality and development were prominent in the included papers: ambiguous guidelines, poorly updated guidelines, rigorous guideline methodology and poorly adapted guidelines. In addition, poor advocacy of guidelines and low adherence to guidelines deterred the implementation of TB diagnostic guidelines and were reported in both LMICs and HI countries [ 6 , 7 , 29 , 35 , 37 – 41 , 44 ]. The ambiguity in guideline recommendations was due to guidelines being nonspecific to certain subgroups of patients.…”

“…Limited education on guidelines and TB disease was a barrier to TB diagnostic guideline implementation across all settings [ 6 , 29 , 36 , 37 , 39 , 41 , 43 , 45 , 48 ]. The availability of tools (guidelines, algorithms and care pathways) and training opportunities, such as workshops, practical and face-to-face training sessions, and internet modules, facilitated the implementation of TB diagnostic guidelines and were reported in both LMICs and HI countries [ 8 , 9 , 29 , 31 , 34 , 37 , 40 , 41 , 45 ]. Poor patient flow processes were also a significant barrier to the implementation of TB diagnostic guidelines in both LMICs and HI countries [ 6 , 8 , 30 , 31 , 35 , 43 , 46 ].…”