尽管尼日利亚自2011年以来获得了免费的耐药结核病(DR-TB)护理,但该国仍在继续解决低病例通报率和治疗率问题。2018年,估计21,000例病例中有11%被诊断出,9%接受治疗。然而,这些低发病率与2015年相比有了显著改善,当时只有3.4%的人被诊断出,2.3%的人接受了估计的29,000例病例的治疗。这项研究描述了2013年至2017年尼日利亚DR-TB护理级联,并考虑了影响护理差距的因素。
■我们的研究采用了混合方法设计。对于定量成分,我们利用了国家诊断和治疗数据库,以及世界卫生组织对构建5年护理级联的患病率的估计:每个DR-TB护理级别的患者人数,包括事件案例,访问测试的个人,被诊断出来,2013年至2017年在尼日利亚开始治疗并完成治疗。使用2015年诊断的患者的回顾性数据,我们进行了Fisher精确检验,以确定患者(年龄和性别)和提供者/患者(地区-南北)变量之间的关联。允许更仔细地观察5年来在护理方面显示的差距。使用57个定性访谈的框架主题分析和与患者的焦点小组讨论来探索护理障碍,包括2015年队列中未开始治疗的5例病例,治疗支持者,社区成员,2017年医护人员和项目经理。
■对护理数据级联的5年分析表明,但不够,获得护理的病例总数增加。平均而言,在2013年至2017年期间,80%的估计病例未通过检测;75%的检测患者未得到诊断;36%的诊断患者未开始治疗,其中23%未完成治疗.2015年,尼日利亚北部的儿童和患者在诊断后完成治疗的几率为0.3[95%CI0.1-0.7]和0.4[0.3-0.5];而男性在诊断后完成治疗的几率为1.34[95%CI1.0-1.7]倍。定性数据的主要主题确定了个人护理级联过程中的护理障碍,家庭和社区,以及卫生系统水平。在个人层面,缺乏对疾病真正原因的认识和“免费”护理的可用性是一个反复出现的主题。家庭干预被认为是儿童和妇女面临的特殊挑战。在卫生系统层面,怀疑指数低,缺乏快速诊断工具和人力资源短缺似乎限制了患者的访问。
■诊断技术和较短方案的任何收益都会因获得DR-TB服务的不足而丧失。尼日利亚级联中最大的损失发生在治疗开始之前。有必要对已查明的DR-TB级联中的差距采取紧急行动,以改善多个阶段的护理连续性,改善尼日利亚的卫生服务提供并促进结核病控制。
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: 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 gaps in the DR-TB cascade in order to improve care continuity at multiple stages, improve health service delivery and facilitate TB control in Nigeria.