Highlights
- Quick and dependable TB diagnostic methods enable early treatment initiation.
- Failure to start TB treatment results in poor patient outcomes and the spread of the disease among community members.
- A reminder message sent to patients who have tested positive for tuberculosis has the potential to help overcome both patient and healthcare system related barriers to treatment initiation.
Background
Tuberculosis (TB) has long been a major public health issue in many countries, including South Africa (which is among the top 30 high TB burden countries globally). In South Africa, the TB incidence rate is about 513 cases per 100,000 people and at least 53% of them are co-infected with HIV. The rate of failure to initiate TB treatment ranges between 14.9% and 17.9% in the country but can reach 22.5% in densely populated economic hubs like inner-city Johannesburg. These rates are significantly higher than the country's national TB control programme's target of "less than 5%."
There are several reasons why TB patients do not start treatment, which can be classified as patient-related factors or healthcare-system-related factors. Patient-related factors include a lack of motivation for a subsequent visit and other competing priorities, resulting in a failure to return to the clinic or hospital, whereas healthcare-system-related factors include being unaware or unsure of appointment dates, as well as poor healthcare-provider and patient communication on next steps after testing.
It is important that patients who have been tested for TB receive their results so that treatment can begin if necessary. To reduce community transmissions, strategies must be in place to ensure that TB patients begin treatment quickly.
Reminding patients to return to the health facility for their results is one way to ensure that those who require treatment receive it. This can be accomplished by leveraging existing healthcare systems and incorporating digital methods. Between 2018 and 2020, a study was conducted in Johannesburg, South Africa, to assess the effectiveness of Ward-based Outreach Teams (WBOTs) and Short Message Service (SMS) technology in improving TB treatment initiation.
Research methods
A mixed methods research approach was used, with two phases (formative and intervention). Secondary data were analysed for frequency distributions in the formative phase to determine the rates of failure to initiate TB treatment. In addition, in-depth interviews were conducted with WBOT Managers and TB Programme Managers to determine their perceived reasons for failure to initiate TB treatment. During the intervention phase, two interventions (WBOTs/SMS technology) were tested in a three-arm randomized controlled trial (RCT), with each intervention compared to the standard of care (SOC) of doing nothing. WBOTs distributed paper slip reminders, whereas SMS intervention entailed sending patients reminder SMS messages as soon as TB results were available. The RCT was followed by in-depth interviews with WBOT members and trial participants who had tested positive for TB and had received reminder messages.
Key findings
Failure to initiate TB treatment was found in roughly one in every four patients during the formative phase, with an overall time to treatment initiation of 9 days. Untreated patients are known to infect as many as 15 other people. Interviews with managers revealed that the main patient-related factors found as reasons for lack of treatment initiation were relocation and "shopping around"[1]. Lack of communication and staff rotations were common healthcare-system-related factors.
Referral of symptomatic patients for TB testing and adherence monitoring in patients already on TB treatment were found to be integrated services in WBOT/TB programmes. In the SMS group, more patients were started on TB treatment than in the SOC group. Patients in the SMS group also received treatment sooner than those in the SOC group (4 days versus 8 days).
A comparison of the WBOTs and SOC groups revealed similar proportions of patients started on treatment as well as similar duration to treatment initiation. According to the findings of the post-trial interviews, the WBOTs' delivery of the reminder paper slips during the trial was novel, and easily incorporated into their daily routine.
The patient interviews revealed that the reminder messages aroused a range of emotions (including happiness, fear, and worry). The patient also stated that receiving the reminder message influenced their decision to return to the clinic to collect their results and get started on treatment.
Conclusion
Reminder messages to patients can help patients begin TB treatment sooner. SMS messaging could be used in national TB programmes because it is a low-cost and practical method. WBOTs have the potential to contribute to improved treatment initiation when TB and WBOT programmes are properly integrated.
Policy implications
- It is likely that the TB success rate is overestimated because it is calculated using only TB patients who have begun treatment instead of all patients diagnosed with TB. As a result, a revision of the TB success rate as a national target is necessary.
- SMS messaging to patients is a low-cost intervention that national TB control programmes should implement.
- WBOT's scope of work could be expanded to include participation in TB treatment initiation.
Recommendations
To ensure the continuity of TB services, all clinic staff (regardless of work area) must be regularly trained on TB guidelines.
If the TB programme is to be successful, it is critical that the WBOT and TB programmes be integrated.
Author and affiliation
Dr Judith R.M. Mwansa-Kambafwile1,2,3
1Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
2Centre for Tuberculosis, National Institute of Communicable Diseases (NICD), Johannesburg, South Africa..
3Fellow of the Consortium for Advanced Research Training in Africa (CARTA).
Main sources of policy brief
Mwansa-Kambafwile J, Maitshotlo B & Black A. (2017) “Microbiologically Confirmed Tuberculosis: Factors Associated with Pre-Treatment Loss to Follow-Up and Time to Treatment Initiation” PLoS ONE 12(1): e0168659. doi:10.1371/journal.pone. 0168659
Mwansa-Kambafwile, J.R.M., Jewett, S., Chasela, C. Nazir Ismail; & Colin Menezes. Initial loss to follow up of tuberculosis patients in South Africa: perspectives of program managers. BMC Public Health 20, 622 (2020). https://doi.org/10.1186/s12889-020-08739-w
Mwansa-Kambafwile, J., Chasela, C., Levin, J., Ismail, N., & Menezes, C. (2022). Treatment initiation among tuberculosis patients: the role of short message service (SMS) technology and Ward-based outreach teams (WBOTs). BMC public health, 22(1), 318. https://doi.org/10.1186/s12889-022-12736-6
Mwansa-Kambafwile JRM; PhD Thesis: Treatment initiation among tuberculosis patients: the role of short message service (SMS) technology and Ward-based outreach teams (WBOTs) (2022); School of Public Health, Faculty of Health Sciences, University of Witwatersrand
Other references
Cele, L. P., Knight, S., Dlungwane, T., Webb, E., & Tint, K. (2016). High level of initial default among smear positive pulmonary tuberculosis in eThekwini health district, KwaZulu-Natal. Southern African Journal of Infectious Diseases, 31(2), 41-43.
Churchyard, G. J., Stevens, W. S., Mametja, L. D., McCarthy, K. M., Chihota, V., et al. (2015). Xpert MTB/RIF versus sputum microscopy as the initial diagnostic test for tuberculosis: a cluster-randomised trial embedded in South African roll-out of Xpert MTB/RIF. The Lancet Global Health, 3(8), e450-e457.
Pillai, D., Purty, A. J., Prabakaran, S., Singh, Z., Soundappan, G., & Anandan, V. (2015). Initial default among tuberculosis patients diagnosed in selected medical colleges of Puducherry: issues and possible interventions. Int J Med Sci Public Health, 4(7), 957-960.
Rao, N., Anwer, T., Arain, I., & Ara, I. (2011). To evaluate primary default among smear positive pulmonary tuberculosis patients at three chest clinics of Ojha Institute of Chest Diseases, Karachi, Pakistan.
Rawat, J., Biswas, D., Sindhwani, G., Kesharwani, V., Masih, V., & Chauhan, B. S. (2012). Diagnostic defaulters: an overlooked aspect in the Indian revised National Tuberculosis Control Program. The Journal of Infection in Developing Countries, 6(01), 20-22.
SA NDOH (2014). National Tuberculosis Management Guidelines. South African National Department of Health.
World Health Organization. (2022). Global tuberculosis report 2022. World health organization.
Zailinawati, A. H., Ng, C. J., & Nik-Sherina, H. (2006). Why do patients with chronic illnesses fail to keep their appointments? A telephone interview. Asia Pacific Journal of Public Health, 18(1), 10-15.
[1] Shopping around refers to patients getting tested at different facilities after they receive a positive TB test result
