Task shifting for tuberculosis control: A qualitative study of community-based directly observed therapy in urban Uganda

Abstract

This qualitative study of task shifting examined tuberculosis (TB) therapy under modified community-based directly observed treatment short-course (CB-DOTS) in Kampala, Uganda. New TB patients selected one of two strategies: home-based DOTS and clinic-based DOTS. Relevant socio-economic characteristics, treatment-seeking experiences and outcomes were assessed over eight months of follow-up. Of 107 patients recruited, 89 (83%) selected home-based DOTS. Sixty-two patients (70%) under home-based DOTS and 16 patients (89%) under clinic-based DOTS had successful outcomes following completion of tuberculosis therapy. Treatment supporters’ provision of social support beyond observing drug ingestion contributed to successful outcomes under both strategies. Home-based DOTS provides continuity of social support during therapy, strengthening the potential for treatment success. Conventional health facility-based DOTS can be modified in resource-limited urban Africa to offer a viable DOTS strategy that is sensitive to personal preference. Shifting the task of DOTS support away from only qualified health workers to include laypersons in the patients’ social-support network may contribute to meeting World Health Organization (WHO) treatment targets. We recommend an intervention evaluating this modified DOTS strategy on a larger scale in TB high-burden, resource-poor urban settings.

Keywords:

• tuberculosis
• community-based DOTS
• task shifting
• social network support
• Uganda

Acknowledgements

We thank the staff of Uganda-Makerere University – Case Western Reserve University Research collaboration and the Kawempe Community Health Study team, particularly Dr Sarah Zalwango and Dr Lorna Nshuti, for their contribution to the study field activities. We also thank the research team: Joan Nanfuka, Stella Nanyonga, Keziron Muwanga (RIP), Mustafa Mubiru, James Kimera, Elias Sakku, Mike Odie, Kyle Luman and Edward Ssali. We thank Profs. Charles B. Rwabukwali and David Guwatudde for the scientific advice and support provided. This project received financial support from the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), project # A40245, and the AIDS International Training and Research Programme (AITRP) at Case Western Reserve University, Grant #TW000011, funded by the Fogarty International Center of the National Institutes of Health.