Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method study

Abstract

Background Despite the availability of free drug-resistant tuberculosis (DR-TB) care in Nigeria since 2011, the country continues to tackle low case notification and treatment rates. In 2018, 11% of an estimated 21,000 cases were diagnosed and 9% placed on treatment. These low rates are nevertheless a marked improvement from 2015 when only 3.4% were diagnosed and 2.3% placed on treatment of an estimated 29,000 cases. This study describes the Nigerian DR-TB care cascade from 2013 to 2017 and considers factors influencing gaps in care. Methods Our study utilized a mixed-method design. For the quantitative component, we utilized the national diagnosis and treatment databases, as well as the World Health Organization’s estimates for prevalence to construct a 5-year care cascade: numbers of patients at each level of DR-TB care, including incident cases, individuals who accessed testing, were diagnosed, initiated treated and completed treatment in Nigeria between 2013 and 2017. Using retrospective data for patients diagnosed in 2015, we performed the Fisher’s exact test to determine the association between patient (age and gender) and provider/patient (region- north or south) variables, permitting a closer look at the gaps in care revealed across the 5 years. Barriers to care were explored using framework thematic analysis of 57 qualitative interviews and focus group discussions with patients, including 5 cases not initiated on treatment from the 2015 cohort, treatment supporters, community members, healthcare workers and program managers in 2017. Results A 5-year analysis of cascade of care data shows significant, but inadequate, increases in overall numbers of cases accessing care. On average, between 2013 and 2017, 80% of estimated cases did not access testing; 75% of those who tested were not diagnosed; 36% of those diagnosed were not initiated on treatment and 23% of these did not finish treatment. In 2015, children and patients in Northern Nigeria had odds of 0.3 [95% CI 0.1–0.7] and 0.4 [0.3–0.5] of completing treatment once diagnosed; while males were shown to have a 1.34 [95% CI 1.0–1.7] times greater chance of completing treatment after diagnosis. The main themes from qualitative data identified barriers to care along the care cascade at individual, family and community, as well as health systems levels. At the individual level, a lack of awareness of the true cause of disease and the availability of ‘free’ care was a recurring theme. Family interference was found to be a particular challenge for children and women. At the health system level, low index of suspicion, lack of rapid diagnostic tools and human resource shortages appeared to limit patients’ access. Conclusions Any gains in diagnostic technology and shorter regimens are lost with inadequate access to DR-TB services. The biggest losses in the Nigerian cascade happen before treatment initiation. There is a need for urgent action on identified gap...

Gaps and Interventions across the Diagnostic Care Cascade of TB Patients at the Level of Patient, Community and Health System: A Qualitative Review of the Literature

“…Many people also believe that government health services are not of good quality [ 54 , 55 ]. Addressing people’s knowledge gaps through community awareness programmes [ 23 , 56 ] and adopting intensive, state-of-the-art, and multidimensional interventions to support active case finding can dramatically improve local TB epidemics [ 3 , 29 ]. In one such programme, an awareness campaign and cell phone-based provisional cash transfers to all people screened at private clinics doubled TB notifications [ 55 ].…”

“…Another reason for not seeking care with health facilities is that patients may not have care-seeking behaviour [ 56 ]. Public education strategies via TV, radio, or other electronic social media can modify this behaviour.…”

“…Many patients with DR-TB are lost due to misdiagnosis, low provider index of doubt, or challenges related to health facilities [ 56 ]. In most LMICs, private providers are the main point of healthcare [ 40 ].…”

Individual journeys to tuberculosis care in Nigeria’s private sector during the COVID-19 pandemic

“…Our conceptual framework (figure 1) is derived from existing literature29 31–33 and highlights two main types of delays along pathways to TB care: health-seeking and health system delays. Health-seeking delays are defined as the time it takes from symptom onset to patients recognising their symptoms and seeking care from a healthcare provider.…”

“…These delays can lead to three major gaps or missed opportunities in accessing TB care: Gap 1 includes those who never access TB testing, Gap 2 are those who access testing but are not diagnosed and Gap 3 includes those diagnosed but not treated. These gaps result in prolonged illness, disease transmission, increased risk of drug-resistant TB and death 1 32 33. Studies done in Nigeria before the pandemic identified Gap 1 as the biggest challenge in TB control, followed by Gap 2 5 32 35 41…”