![RQ2. Barriers to Outpatient TB Treatment
Adherence for Patients in At-Risk Groups
I get nauseous from time to time. But I am home, so I
go, lay down. I often have a headache. Nausea not so
much. Mainly, it is a headache and sleepiness. That is
why it was difficult for me to get there [to the HF].
This way, I am close to home. I climb up to my floor,
lay down, and it no longer matters whether I am
sleepy or not, have a headache or not. I am near my
home—I take the pills, go upstairs, and I am at home.
I no longer need to overcome a commute. To stand
there waiting for the minivan. In this crowd you also
get a headache. Sometimes you also get sick from
these pills. (Patient)](https://image.slidesharecdn.com/ukrainesspresentationfinalengtogretchen-180323165623/85/Evaluation-of-the-Impact-of-a-Social-Support-Strategy-on-Treatment-Outcomes-37-320.jpg)
Evaluation of the Impact of a Social Support Strategy on Treatment Outcomes
- 1. Evaluation of the Impact of a Social Support Strategy on Treatment Outcomes Zulfiya Charyeva Nicole Judice MEASURE Evaluation, Palladium
- 2. Global, five-year, $232M cooperative agreement 6 partners, led by the University of North Carolina at Chapel Hill Strategic objective: Strengthen capacity in developing countries to gather, interpret, use data to improve health MEASURE Evaluation Overview
- 3. Local Partners and Capacity Building are Key Prime—UNC-CH and partners: ICF John Snow, Inc. Management Sciences for Health Palladium Tulane University MEASURE Evaluation works with more than 72 smaller sub-awardees in over 27 countries Over 26 percent of project funding goes back to minor sub-awardees
- 4. Global Footprint (more than 40 countries)
- 5. Tuberculosis in Ukraine • One of 30 countries with the highest burden of MDR-tuberculosis (TB) • 22,000 new cases of MDR-TB in 2015 • Incidence rate increase by 20 percent or more between 2014 and 2015
- 6. Strengthening TB Control in Ukraine Project (STbCU) • Goal—Reduce the burden of TB through specific quality assurance and system strengthening measures for routine TB services, MDR-TB, and HIV coinfection • Provide social support to promote patient adherence to TB treatment • Improve access and use of timely diagnostic and treatment for HIV coinfected patients to reduce mortality
- 9. Strengthening TB Control in Ukraine Project (STbCU) • Goal—Reduce the burden of TB through specific quality assurance and system strengthening measures for routine TB services, MDR-TB, and HIV coinfection • Provide social support (SS) to promote patient adherence to TB treatment (Social Support Study) • Improve access and use of timely diagnostic and treatment for HIV coinfected patients to reduce mortality (TB-HIV Integration study)
- 10. Social Support Program • Implemented by the Ukrainian Red Cross Society (URCS) under the STbCU Grant-01 • Nurses: • provided DOTS* treatment to selected patients, in the patients’ homes • distributed diaries with information materials • provided social support * DOTS—Directly Observed Treatment Short Course
- 11. Social Support Program Eligibility • HIV-positive • Alcoholics • People who inject drugs • TB contacts • Homeless • Migrants • Refugees • Ex-prisoners • Unemployed • Persons with comorbidities • Others
- 12. Evaluation Design A mixed-methods approach with a quasi-experimental quantitative evaluation design complemented by qualitative descriptive work to inform the findings
- 13. Impact Evaluation Questions: Social Support Study • 1. Does participation in a social support program affect the likelihood of TB treatment default, treatment success, or treatment failure among high-risk patients? • 2. What aspects of outpatient TB treatments make adherence particularly difficult for patients in at- risk groups?
- 14. Impact Evaluation Questions: Social Support Study (2) • 3. What aspects of the social support program are most important to those receiving the program? What works best for ensuring adherence? • 4. What is the estimated effect of the SS program on the treatment success rate at the population level?
- 15. Summary of Methods, Table 1 Question Data collection Data sources Sample Sample size Analysis 1. Chart abstraction Patient medical records; TB manager Systematic random sampling 2,327 charts Logistic regression 2,3. In-depth interviews (IDIs) Patients, providers, STbCU and URCS staff Purposive 21 program beneficiaries, 11 nurses, and 4 program coordinators Qualitative data analysis 4. Chart abstraction Patient medical records; TB manager Systematic random 1,030 patient charts Frequencies; decomposition model Context Facility Facility lead doctors and administrators All facilities in the three regions 48 HFs, 2 URCS regional offices Descriptive statistics
- 16. Social Support Study Oblasts • Dnipropetrovsk, Kharkiv, Odessa • Selected purposively based on: • high treatment default rates • adequate caseload to support the sample design
- 17. Definition of Study Cohort Risk Groups • High-risk (HR) intervention patient—Everyone on the URCS patient list • High-risk nonintervention patient—Any patient with one or more of the following risk factors, who was not receiving SS services: HIV-positive, alcoholics, people who inject drugs, TB contacts, homeless, migrants, refugees, ex-prisoners, and persons with comorbidities • Low-risk (LR) nonintervention patient—Any patient without any risk factor, except for the unemployed
- 18. Evaluation Design at Phase 1 • Retrospective extraction of medical records of TB patients seen in 2011 and 2012 (Jan–May) • Five cohorts in three regions, 445 patients each: • High-risk, enrolled in SS in 2012—intervention group • High-risk, not enrolled in SS in 2012 • Low-risk patients not enrolled in SS in 2012 • High-risk patients not enrolled in SS in 2011 • Low-risk patients not enrolled in SS in 2011 • Facility survey of facilities from which patients were selected and URCS offices in each oblast
- 19. Evaluation Design at Phase 2 • Retrospective extraction of medical records of TB patients seen in 2014 and 2015 (Jan–Sept) • Five cohorts in three regions, 445 patients each: • High-risk, enrolled in SS in 2014—intervention group • High-risk, not enrolled in SS in 2014 • Low-risk patients not enrolled in SS in 2014 • High-risk patients not enrolled in SS in 2015 • Low-risk patients not enrolled in SS in 2015 • Survey of facilities from which patients were selected and URCS offices in each oblast • Qualitative study to inform findings
- 20. Findings
- 21. Program Context • One facility experienced drug shortages lasting longer than 30 days during 2014. • Four (8.6 percent) reported shortages in 2015. • 79% of facilities provided SS referrals in 2014 versus 33% in 2015.
- 22. RQ1. Does Participation in a SS Program Improve TB Outcomes for HR Patients? • Similar demographic profiles across risk cohorts and years (Table A5); Fewer HR patients reported being employed. • Among the HR cohorts, 54–71 percent reported 2–3 risk factors for treatment default. • 74.6 % of the intervention cohort reported no treatment interruptions, compared with 71.1% of the 2014 HR comparison group and 54.7% of the 2015 HR comparison group.
- 23. RQ1. Does Participation in a SS Program Improve TB Outcomes for HR Patients? • The HR intervention cohort experienced significantly greater treatment success than the other two HR comparison groups (88.4% treatment success vs. 67.5% and 76.7%; Table 3). • p<0.0001 for both comparisons
- 24. Group Work • Review Table 3 • Compare the proportion of patients with interrupted treatment and proportion of patients who died among HR cohorts. What conclusions do you have? • Compare TB treatment outcomes for the HR intervention group to the LR comparison cohorts in 2014 and 2015. What conclusions do you have?
- 25. Treatment Success, by Risk Cohort and Year, % (Phase 1 and Phase 2) 88.2 88.4 70.1 67.5 72.3 76.7 84.9 80.9 90.6 88.9 0 10 20 30 40 50 60 70 80 90 100 2012 2014 2012 2014 2011 2015 2012 2014 2011 2015 Intervention Comparison Comparison Comparison Comparison High-Risk Patients Low-Risk Patients Percentage
- 26. Social Support Program Helped to Prevent Treatment Default Predicted probability of treatment default and marginal effects of the intervention 0.6 5.8 5.1 0.6 8.5 7.8 0 1 2 3 4 5 6 7 8 9 10 HR Int 2014 HR No Int 2014 Marginal effect HR Int 2014 HR No Int 2015 Marginal effect % Predicted Probabilities, %
- 27. Social Support Program Reduced Probability of Dying Predicted probability of dying and marginal effects of the intervention 2.1 6.7 4.6 2.1 4.3 2.2 0 1 2 3 4 5 6 7 8 9 10 HR Int 2014 HR No Int 2014 Marginal effect HR Int 2014 HR No Int 2015 Marginal effect % Predicted probabilities, %
- 28. Group Work • Review Tables 4 and 5. What can you tell about oblast differences in the probability of treatment default? • Review Tables 6 and 7. What can you tell about oblast differences in the probability of dying?
- 29. RQ1. Conclusions • The Phase 2 study results are consistent with the Phase 1 findings. • Participation in the SS intervention improves TB treatment outcomes among HR patients. • The intervention cohort has higher treatment success and lower likelihood of treatment default and dying than the other two HR comparison groups. • The intervention cohort has similar TB treatment outcomes as the LR cohorts.
- 30. RQ4. The Effect of the SS Program on the Treatment Success Rate at the Population Level • The 2014 SS program reduced the population- level default rate by approximately 20% from what it might have been without it. In 2014, the URCS program reduced the number of patients defaulting on treatment by 74 patients (reduction from 362 to 288 patients). • If the URCS program had been continued and expanded to cover all HR patients in 2015, the estimated default rate was 2.6%, which translates to 198 patients defaulting.
- 31. • Stopping the URCS program in 2015 was associated with an increase of 31.2 percent in the default rate, compared with what it would have been if the program had been maintained (increase in default rate from 4.84 to 6.35). • This translates to 113 more patients defaulting on treatment (increase from 362 to 475 patients). RQ4. The Effect of the SS Program on the Treatment Success Rate at the Population Level
- 32. Number of Patients with Treatment Default, by SS Program Coverage and Year (modeling) 362 475 288 475 182 198 0 50 100 150 200 250 300 350 400 450 500 2014 2015 No social support services Observed coverage of social support services All high risk patients received URCS social support services
- 33. RQ 2 and RQ 3. Study Participants City Region Number of patients interviewed Number of providers interviewed Number of program coordinators Odessa Odessa 10 5 1 Dnipro Dnipro- Petrovsk 4 2 1 Kryvyi Rih Dnipro- Petrovsk 5 2 Nikopol Dnipro- Petrovsk 2 2 Kiev Kiev 2 Total 21 11 4
- 34. RQ2. Barriers to Outpatient TB Treatment Adherence for Patients in At-Risk Groups Prior to joining the SS program: • Weakness and side effects from medicine • Length of time required daily to receive outpatient treatment at a HF • HF hours of operation • Fear of getting reinfected with another TB strain at a HF • Stigma • Transportation expenses • Lack of motivation to get treated
- 35. RQ2. Barriers to Outpatient TB Treatment Adherence for Patients in At-Risk Groups I started treatment in May. . . . From the very beginning of treatment, I started having nausea and I was very sleepy. As I kept taking pills, my condition worsened. . . . It was a long way to a HF. I had to wait for the minivan. I felt dizzy from the crowd in the minivan too. I felt weak and almost fainted from these pills. . . . Sometimes I missed my stops when I was riding a minivan. I did not feel well. . . . There were a few days when I could not get to the HF because I could not make myself get up and go. This was because of the side effects from the pills. These are strong pills. (Patient)
- 36. RQ2. Barriers to Outpatient TB Treatment Adherence for Patients in At-Risk Groups SS program addressed most of the treatment adherence barriers. • They allowed patients to avoid travel to clinics, which addressed the following: • logistical barriers associated with travel time and costs • discomfort from side effects during travel • wait time at HFs • stigma and fear of further infection • Program supported patients to handle side effects and depression.
- 37. RQ2. Barriers to Outpatient TB Treatment Adherence for Patients in At-Risk Groups I get nauseous from time to time. But I am home, so I go, lay down. I often have a headache. Nausea not so much. Mainly, it is a headache and sleepiness. That is why it was difficult for me to get there [to the HF]. This way, I am close to home. I climb up to my floor, lay down, and it no longer matters whether I am sleepy or not, have a headache or not. I am near my home—I take the pills, go upstairs, and I am at home. I no longer need to overcome a commute. To stand there waiting for the minivan. In this crowd you also get a headache. Sometimes you also get sick from these pills. (Patient)
- 38. RQ3. Most Important Aspects of the SS Program for Patients—What Worked Best for Ensuring Adherence • Convenience, because pills were brought to the patients daily • Support provided by the URCS nurses
- 39. RQ3. Most Important Aspects of the SS Program for Patients—What Worked Best for Ensuring Adherence • Emotional, informational, instrumental, and motivational support. • It was important to patients that: • nurses cared about their well-being and treated them as equals • nurses provided information, and encouraged and motivated them to stay on treatment • patients received individual attention from nurses
- 40. • Patients appreciated and valued the SS program and felt that it helped them to stay on treatment. • Patients were often isolated from society and felt lonely. It was very important for them to have someone in their lives who cared about them. RQ3. Most Important Aspects of the SS Program for Patients—What Worked Best for Ensuring Adherence
- 41. • Simply, it’s pleasant to receive someone’s attention. She will calm me down, will say, “It’s okay. Everything will be ok. You will heal.” You know, it is very hard to have this disease. We all think that none of us will be affected. Things happen in life. None of us are protected from it. With her I was able to talk about this, I was able to open up to her and express my worries. She would calm me down. (Patient) RQ3. Most Important Aspects of the SS Program for Patients—What Worked Best for Ensuring Adherence
- 42. • . . . It turns out that you feel needed. . . . The nurse stands behind you with her support, as if she is family. Right now, there are rarely families in which the members talk and help each other. This support helps. She brings the pills, talks, and provides advice. (Patient) RQ3. Most Important Aspects of the SS Program for Patients—What Worked Best for Ensuring Adherence
- 43. • Such a program should exist because in such a program . . . many ill patients who get treatment in the hospital do not have the motivation to go through the treatment to get better. But here they encourage and support you, tell you that treatment is necessary; they explain it. And for me, I want to live, and I want to undergo the treatment. (Patient) RQ3. Most Important Aspects of the SS Program for Patients—What Worked Best for Ensuring Adherence
- 44. Questions
- 45. MEASURE Evaluation is funded by the U.S. Agency for International Development (USAID) under terms of Cooperative Agreement AID-OAA-L-14-00004 and implemented by the Carolina Population Center, University of North Carolina at Chapel Hill in partnership with ICF International, John Snow, Inc., Management Sciences for Health, Palladium Group, and Tulane University. The views expressed in this presentation do not necessarily reflect the views of USAID or the United States government. www.measureevaluation.org