“Intensified case finding of tuberculosis among diabetes mellitus patients attending non-communicable disease clinic in a tertiary care hospital – An implementation research”

Abstract

Background

For ending the epidemic of TB by the year 2030, along in line with Sustainable Development Goals, it is essential to address the TB associated co-morbidities. Prevalence of diabetes influencing TB incidence and mortality is higher when compared to other co-morbidities like HIV infection, smoking, alcoholism and malnutrition. Therefore, this study was conducted with the following objectives: 1.To evaluate the effectiveness of the intervention on implementation of TB-DM collaborative activity using four symptom complex strategy and to explore the patient and healthcare providers related factors that contribute in implementation of the activity.

Material and methods

The present study was undertaken by Department of Community Medicine, Sri Manankula Vinayagar Medical College and Hospital, Puducherry for a period of 18 months in the Out Patient Departments of General Medicine, General Surgery, Obstetrics and Gynecology, Orthopedics, DOTS center and Designated Microscopy Centre. It was an embedded sequential experimental study, done among the health care professionals (CRRI, Postgraduates and staff nurse) who were involved in process of 4s complex screening for DM patients and the stakeholders who were involved in implementation of NTEP activity. The study was conducted in three phases. Phase I: baseline survey and identification of intervention strategies, Phase II: implementation of the intervention and Phase III: end line survey.

Data entry and analysis

Manual content analysis was done for Qualitative data. The Quantitative data were entered into Epi Info software (version 7.2.2.6) and analyzed in SPSS software (version 24). Comparison of knowledge among the health care professionals before and after sensitization was calculated using Mc nemar test. It was considered statistically significant when the p value was <0.005. The analysis of free list and pile sort data was undertaken using Anthropac 4.98.1/X software.

Results

Challenges obtained from stakeholders in implementing the activity were categorized as patient related factor, health care professional related factor and screening and reporting related factor. Suggested solutions were generating awareness at patient level, display of IEC tools, periodical sensitization for the staff, inter-departmental co-ordination, monitoring and re-enforcing the activity in core-committee meetings. After sensitization, the knowledge on joint TB-DM collaborative activity was significantly improved among the health care professionals. By implementing the four symptom complex screening activity in NCD clinic, 6480 DM patients were screened and 176 (2.7%) presumptive TB cases were identified. Of which, 136 of them reached DMC for sputum examination. Among them 44 (35.4%) had active TB infection. The Number Needed to Screen to yield a case of TB was 147.

Conclusion and recommendations

We found improvement in identification of TB cases using ICF approach with minimal resources. Thus, we recommend a support group to maintain and strengthen the ongoing activity. The challenges and solutions identified may help in optimizing the screening process. Implementing the activity in special clinics like oncology OPDs, nephrology OPDs, antenatal clinics can be recommended.