Identifying barriers to TB diagnosis and treatment under a new rapid diagnostic scheme.

Lead Research Organisation: Liverpool School of Tropical Medicine
Department Name: Child and Reproductive Health

Abstract

Abstracts are not currently available in GtR for all funded research. This is normally because the abstract was not required at the time of proposal submission, but may be because it included sensitive information such as personal details.
 
Description The scientific impact(s) are:
1. Developed a robust evidence base to illustrate the multiple barriers and costs patients face accessing tuberculosis diagnostics through the standard passive case finding approach in Ethiopia, Yemen and Nigeria. 2. Methodological innovation through deploying a range of methods to develop a robust evidence base. Our project was one of the first in Yemen to use qualitative methods to explore community's experiences of a health issue and we have written up the methodological and gender issues arising when using in-depth interviews and focus group discussions in this context (see SAGE Cases in Methodology series paper). 3. Supported the development of new models and approaches for close to community service provision in Ethiopia, Yemen and Nigeria. 4. Supported policy dialogue and discussions about how a same day smear microscopy (tuberculosis diagnostic) process could assist patients by reducing direct and opportunity costs of multiple visits to a health centre.

The findings and outputs which have had the scientific impact(s):
Findings/outputs: Accessing services resulted in significant costs, especially clinic fees and transport and particularly among accompanied adults and adults from rural areas. Most participants (particularly women) attended the services with companions and were unprepared for the duration of the process. Women faced particular difficulties to access services. Patients faced multiple barriers to complete TB diagnosis and the shorter schemes could assist patients by reducing costs, especially if the process is completed in one day. The studies highlighted that access to services is a major barrier and service delivery strategies that identify symptomatic adults at home are important.

The findings and outputs which have had the economic and societal impact(s):
There were economic costs associated with attending diagnostic services in all the contexts. The most significant expenses incurred were for clinic fees and transport. Many factors were associated with high expenditure. The main contributors across all settings were attending the services with company and rural residency. Costs for first and second day attendance were comparable. Most participants (particularly women) attended the services with companions - considerably increasing the cost of diagnosis and patients who were often unprepared for the duration of the process. There is some mistrust of government health services among patients who then consult private practitioners during and after attendance at diagnostic services. There is also considerable social stigma surrounding tuberculosis and testing , which jeopardise attendance at services and lead to social isolation and employment difficulties. Patients report difficulties in returning to the diagnostic services for the second day of diagnosis, due to commitments at work and home and financial constraints. These findings particularly highlight that stationary services located at a relatively long distance from the patients' residence are a major obstacle to accessing TB diagnosis and that bringing the services at closer proximity to communities is important, as is a shorter diagnostic pathway.

These impacts were achieved:
Firstly through generating the robust evidence on social and economic costs associated with seeking tuberculosis care. This was then built upon through developing strategies to bring services closer to communities to attempt to address these costs and through policy dialogue about tuberculosis diagnosis.
Exploitation Route Potential Future Impacts:
We will continue to work in partnership to evaluate and pool learning from across the different projects which are using innovative approaches to bring tuberculosis closer to communities. We will share the concepts, findings and approaches through peer reviewed papers, policy briefs and ongoing dialogue with high level stakeholders including the World Health Organisation, Global
Fund to Fight AIDS, Tuberculosis and Malaria and the International Union Against Tuberculosis and Lung Disease who can use them as appropriate. With the current global focus on universal health coverage we anticipate increasing interest in approaches that bring services closer to communities and address the multiple barriers poor and vulnerable communities face in accessing care.
Sectors Healthcare,Pharmaceuticals and Medical Biotechnology

 
Description The impacts were achieved: 1. Through presenting findings at high profile and relevant conferences such as the International Union Against Tuberculosis and Lung Disease, 2012 2. Through successfully working in partnership to generate multiplier funding to test out new models. These are active and currently being evaluated. 3. Through participation in the World Health Organisation Scientific Advisory Group and Expert committees. Through on-going policy dialogues within the World Health Organisation, Global Fund to Fight AIDS, Tuberculosis and Malaria and the International Union Against Tuberculosis and Lung Disease. The findings and outputs had an impact upon: 1. Researchers, academics and students with an interest in tuberculosis and/or international health/equity and gender. 2. Policy makers and practitioners both internationally and within resource poor contexts, including the World Health Organisation. 3. Health workers involved in tuberculosis diagnosis, care and treatment. 4. Communities who are participating in new approaches to bring tuberculosis diagnostics close to communities. The economic and societal impact(s): Using multiple methods, our research demonstrated the social and economic costs of accessing tuberculosis services in resource poor contexts and how they vary both between individuals and different contexts. The evidence generated on the social and economic impacts and costs of accessing tuberculosis diagnosis through the passive case finding approach (which relies on multiple visits to the health centre) in Yemen, Nigeria and Ethiopia has supported and fed into: 1.The approaches and concepts deployed in developing new approaches to bring services closer to households and communities in Ethiopia, Yemen and Nigeria. These show promising results in increasing access to tuberculosis diagnosis and treatment, through addressing the economic challenges and social impacts of accessing care through formal health centres. 2.Policy dialogue and discussions about how same day diagnosis can reduce the detrimental social and economic impacts of diagnostic procedures which require multiple visits to the health centre. The economic and societal impact(s) have been on: 1.Communities (including individuals who have symptoms suggestive of tuberculosis and their famiiles) by improving access to diagnostic services. 2.Health workers involved in tuberculosis diagnosis, care and treatment. 3.Researchers, academics and students with an interest in tuberculosis and/or international health/equity and gender. 4.Policy makers and practitioners both internationally and within resource poor contexts. 5.Donors with an interest in tuberculosis.
Sector Healthcare,Pharmaceuticals and Medical Biotechnology
Impact Types Societal

 
Description Identifying barriers to TB diagnosis and treatment under a new rapid diagnostic scheme
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
Impact We have been successful in influencing international health policy in tuberculosis and the processes here are described in our impact report (one of our nominated outputs). We have brought in £3,026,976 worth of multiplier funding to test out approaches to bring tuberculosis services closer to communities in Ethiopia, Yemen and Nigeria. These are showing very promising results and have attracted interest from multiple players. We have also been successful in feeding into policy dialogue within the World Health Organisation about the process of diagnosing tuberculosis and the importance from a patient perspective of being able to complete the diagnostic process within one day (rather than multiple visits).
 
Description A PPP to increase access to quality TB diagnosis and treatment to slum populations of Abuja through active case finding and diagnostic technologies PIs, Luis Cuevas and Saddiq Abdurrahman, I am co- applicant
Amount $878,537 (USD)
Organisation World Health Organization (WHO) 
Sector Public
Country Global
Start  
 
Description Increased detection of children, women and elderly individuals with smear-positive TB in Yemen (PI with Dr Najla Al-Sonboli)
Amount $287,621 (USD)
Funding ID T9-370114YEM 
Organisation World Health Organization (WHO) 
Sector Public
Country Global
Start 10/2010 
 
Description Increasing TB detection and treatment of poor populations by engaging Proprietary Patent Medicine vendors in Nigeria
Amount $400,000 (USD)
Organisation World Health Organization (WHO) 
Sector Public
Country Global
Start 04/2017 
End 10/2018
 
Description Innovative community-based approaches for enhanced tuberculosis case finding and treatment outcome in Southern Ethiopia (PI with Mohammed Yassin)
Amount $654,721 (USD)
Funding ID T9-370114ETH 
Organisation World Health Organization (WHO) 
Sector Public
Country Global
Start 02/2012 
End 01/2013
 
Description Innovative community-based approaches for enhanced tuberculosis case finding and treatment outcome in Southern Ethiopia (PI with Mohammed Yassin)
Amount $689,163 (USD)
Funding ID T9-370-114ETH 
Organisation World Cancer Research Fund 
Sector Charity/Non Profit
Country Global
Start 10/2010 
End 02/2012
 
Description Making it happen: Increasing access to diagnosis and treatment for tuberculosis in Ethiopia PI L Cuevas and D Datiko
Amount £82,087 (GBP)
Funding ID ES/L007746/1 
Organisation Economic and Social Research Council 
Sector Public
Country United Kingdom
Start 03/2014 
End 04/2015
 
Description Reaching out and Linking in : Health systems and close to community services
Amount € 5,800,000 (EUR)
Funding ID 306090 
Organisation European Commission 
Sector Public
Country European Union (EU)
Start 02/2013 
End 01/2018
 
Description Towards a community test and treat strategy for TB in Ethiopia (Triple-Tc: Test-and Treat TB in the community)
Amount $402,000 (USD)
Organisation World Health Organization (WHO) 
Sector Public
Country Global
Start 04/2017 
End 09/2018
 
Description 1. A panel discussion on the intersectionality of Disability, equity and rights, led by Sally Theobald 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact The panellists included:

Chair: Professor Sally Theobald, Liverpool School of Tropical Medicine
• Margaret Gyapong, Dodowa Health Research Centre, Ghana
Intersectionality and Neglected Tropical Disease: from impact to action
• Janet Price, Disability Researcher and Activist, UK and CREA, India
Practical approaches to disability inclusive people-centred health systems
• Grace Bongololo-Mbera, REACH Trust, Malawi
Exploring chronic lung disease and disability in Malawi: the potential role of community based interventions
• Maria Kett, Leonard Cheshire Disability and Inclusive Development Centre, UK (Also ESRC DFID funded PI)
Conflict, poverty and disabled people: a need for multi-sectoral action

The interactive session, supported by the Impact Initiative, explored how health systems can be strengthened to be more responsive to the priorities of disabled people who often face vulnerability and marginalisation that is shaped by gender, poverty and sexuality.

The panellists opened the session detailing their research and experience and then moved onto a fishbowl format where participants had the opportunity to ask the panellists questions, and then participate on the panel to share their own insights.

It was a lively and engaging session, where the tone/buzz of the discussion was set and captured through a number outputs, including:
- Blog preceding the session to set out some of the key questions
- Flyer to promote the session both for print and online
- Short video to capture key ideas/messages to share on social media
The primary audiences for this session were academics working within health systems research, to apply an intersectionality lens. In addition, the aim was also to engage practitioners, i.e. community health workers.

The concluding symposium statement and press release had a very clear focus on 'intersectionality'. Our session and wider engagement contributed clearly to this outcome, and will continue to do so.
Year(s) Of Engagement Activity 2016
URL http://healthsystemsresearch.org/hsr2016/
 
Description Impact of the ESRC/DFID grant Theobald/Cuevas RES-167-25-0387 and associated multiplier funding 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Description: This document provides an overview of the impact of the impact of the ESRC/DFID grant Theobald/Cuevas RES-167-25-0387 and associated multiplier funding. It has been uploaded separately as it uses more space than allowed in the electronic system on impact. This is one of our 2 nominated outputs.

see summary
Year(s) Of Engagement Activity 2008