“Home is where the patient is”: a patient-centred model of care for MDR-TB. Shona Horter1, Philipp Du Cros2, Beverley Collin2, Lucy Reynolds1, Muhammad Shoaib3, Samuel Kasozi4, Esther Casas3 & Meggy Verputten3 1The
London School of Hygiene and Tropical Medicine; 2Médecins Sans Frontières (MSF), London, UK; 3MSF, Amsterdam, Netherlands ; 4The National TB and Leprosy Programme, Ministry of Health, Uganda
Introduction • Multi-drug resistant tuberculosis (MDR-TB) is resistant to the two most powerful firstline TB drugs and its treatment is lengthy, complex and can have severe side effects. • MDR-TB is an emerging issue globally and Uganda has a reported 500 new cases annually1. • WHO recommends MDR-TB treatment models that are primarily ambulatory (as opposed to hospital-based)2, however there has been little research on patient and staff acceptability of such models in Africa3,4. • Médecins Sans Frontières (MSF) has been delivering home based treatment and care for MDR-TB in collaboration with the Ministry of Health (MoH) in Kitgum, northern Uganda since 2009.
Methods • Qualitative research design, with 30 semistructured interviews and four focus group discussions conducted with key respondents identified through purposive and snowball sampling. • Respondents included MDR-TB patients, family members, health care workers (HCW), village health teams (VHTs), members of the MoH, community members and other non-governmental organisations. • Data were collected in Kitgum and Lamwo districts in northern Uganda and in Kampala, until saturation was achieved. • Thematic and grounded theory analyses were used to identify key emergent themes within participants’ responses. •
‘The treatment I am getting from home is bringing some improvement which is much better than the government hospital.’ Patient 03 MDR-TB Patient on the programme receiving directly observed treatment. Photo credit: Andrea Stultiens
Infection prevention measures Photo credit: Andrea Stultiens
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Aim This qualitative study aims to assess the home based treatment and care of MDR-TB patients in northern Uganda, examining patients’ perceptions, views, experiences and acceptability of treatment and care at home versus in hospital; learning lessons from the past 12 months of MSF’s programme implementation and considering the potential for future treatment delivery nationally.
Patient’s Tukul with incorporated infection prevention measures. Photo credit: Andrea Stultiens
‘I feel home based care is good… I saw during the home based care period patients get a lot of improvement in home than in the hospital... The patient always realises rapid improvement from home because you avoid and minimise the thoughts of home that come in the hospital.’ Family member 05
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Background
Results
Conclusion
Kitgum is a rural district of northern Uganda that is currently comparatively stable but historically has been subjected to conflict and displacement, with deleterious effects on the socio-economic status of the population and health infrastructure.
• Acceptability – home based treatment and care was found have high acceptability; it was accepted by all health care receiving respondents (patients and their family members); the two district MoH respondents; all three VHT respondents; and five of six HCW respondents.
This study provides an example of a homebased model of treatment which is:
In December 2009, MSF set up a comprehensive, decentralized and community based programme to treat DRTB patients in Kitgum. The model of treatment and care in this programme is mainly home based, with initial treatment being delivered to patients in a local isolation unit until they are clinically stable. Infection prevention measures at home are then ensured and patients return home for the duration of their treatment (1824 months). Treatment is delivered 6 days a week, is directly observed and is accompanied by psychosocial support. There are currently 9 MDR-TB and 2 monoresistant TB patients receiving treatment in this programme. 1 MDR-TB and 3 monoresistant TB patients have completed treatment and been cured. .
• Conducive to recovery – the enhanced psychosocial support associated with home based treatment and care and the facilitated delivery of enablers were felt to assist with the recovery process. Patients, family members and HCWs felt this model of care was more conducive to patient recovery than hospital-based care. • Reduced socio-economic barriers – this model of care was associated with fewer socio-economic barriers than hospital based care, including distance, affordability, transport costs, living costs while in hospital and distance from home creating indirect costs through lack of ability for the patient or caretaker to work. • Reduced fears of nosocomial transmission - Several respondents mentioned concerns about catching other infections in hospital settings which were not associated with home based treatment and care.
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Patient-centred Accessible Acceptable
This study found the home based model of treatment and care for MDR-TB to be acceptable, accessible and feasible in this rural Ugandan setting. This demonstrates the potential for implementing decentralised strategies of care in Uganda for MDR-TB. Further research is required to examine the applicability of this model for other settings.
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Acknowledgements Grant acknowledgements: The Parkes Foundation, The Trust Fund (London School of Hygiene and tropical medicine).
References 1. Albert, H et al (2010). Rapid screening of MDR-TB using molecular Line Probe Assay is feasible in Uganda. BMC Infectious Diseases. 10: 41-48 2. WHO (2010). Treatment of Tuberculosis Guidelines. 4th Ed 3. Furin, J et al (2011). Programmatic management of multidrug-resistant tuberculosis: models from three countries. International Journal of Tuberculosis and lung disease. 4. Palacios, E et al (2008). The role of the nurse in the community-based treatment of multidrug-resistant tuberculosis (MDR-TB). International Journal of Tuberculosis and Lung Disease. 7(4): 343-346.