Continuity of care for tuberculosis patients between hospital and primary health care services in South Africa

Dudley, Lilian Diana (2020-03)

Thesis (PhD)--Stellenbosch University, 2020.

Thesis

ENGLISH ABSTRACT : Many tuberculosis (TB) patients in South Africa are admitted to acute care hospitals, but large numbers are lost to care after discharge, and few complete their TB treatment. This contributes to ongoing transmission of TB in communities, frequent hospital readmissions, a high mortality rate and avoidable costs to the health system and society. This thesis studied continuity of care for TB patients discharged from hospital in South Africa. It aimed to describe the problem, identify risk factors for poor continuity of care, synthesise evidence to inform, implement and evaluate an intervention, and produce a policy brief to translate the evidence into policy and practice. The research methods included an observational study, research synthesis, qualitative research, participatory action research, a quasi-experimental study as well as knowledge translation methods to address the various research questions. The study found that a third of TB patients discharged from hospital did not continue TB treatment, and that inadequate clinical management of TB patients in hospital showed a significant correlation with poorer continuity of care and an increased mortality rate. Evidence of strategies to improve continuity of care for chronically ill patients was identified in high-income countries, but no such evidence could be found for TB patients in low and middle-income countries. Using the available evidence and participatory action research, a multicomponent discharge planning and support intervention was designed and implemented in collaboration with a referral hospital in the Western Cape. A before-and-after evaluation found that continuity of care for TB patients improved significantly after implementing the intervention. A process assessment revealed that the characteristics of the intervention, the external context, the persons involved and the methods of implementation had a favourable impact on implementation. Yet the internal context of the hospital was unfavourable for implementation, and in-hospital intervention activities were not sustained. In contrast, information linkages and community-based follow-up and support of TB patients continued. More rigorous studies of interventions to improve continuity of care for TB patients discharged from hospital in similar settings are required. This should be complemented by implementation research to understand and address health systems challenges. Both types of research are needed to effectively translate evidence into practice in the health systems of low and middle-income countries.

AFRIKAANSE OPSOMMING : Vele tuberkulose- (TB-) pasiënte in Suid-Afrika word in die akute sorg hospitaal opgeneem, maar baie verdwyn uit die sorgstelsel ná ontslag, en weinig voltooi hulle TB-behandeling. Dít dra by tot aanhoudende TB-oordrag in gemeenskappe, gereelde hospitaalhertoelating, ’n hoë sterftesyfer en vermybare koste vir die gesondheidstelsel en samelewing. Hierdie studie het ondersoek ingestel na die kontinuïteit van sorg vir TB-pasiënte wat uit hospitale in Suid-Afrika ontslaan word. Die doel was om die probleem te beskryf, risikofaktore vir swak kontinuïteit van sorg te identifiseer, bewyse saam te voeg en op grond daarvan ’n intervensie te ontwerp, te implementeer en te evalueer, en ’n beleidsriglyn op te stel om die bewyse in beleid en praktyk om te skakel. Die navorsingsmetodes het ingesluit ’n waarnemingstudie, navorsingsintese, kwalitatiewe navorsing, deelnemende aksienavorsing, ’n kwasi-eksperimentele studie en kennisoordragmetodes om die verskillende navorsingsvraagstukke te ondersoek. Die resultate dui daarop dat ’n derde van TB-pasiënte wat uit die hospitaal ontslaan word, nie met TB-behandeling voortgaan nie, en dat onvoldoende kliniese bestuur van TB-pasiënte in die hospitaal ’n beduidende verband toon met swakker sorgkontinuïteit en ’n hoër sterftesyfer. Bewyse van strategieë om sorgkontinuïteit vir chroniese siek pasiënte te verbeter is in hoë-inkomstelande geïdentifiseer; tog is daar geen bewyse van soortgelyke strategieë vir TB-pasiënte in lae- en middelinkomstelande nie. Met behulp van die beskikbare bewyse en deelnemende aksienavorsing is ’n ontslagbeplanning- en ondersteuningsintervensie met verskeie komponente derhalwe in samewerking met ’n verwysingshospitaal in die Wes-Kaap ontwerp en geïmplementeer. ’n Evaluering voor en ná die tyd bevind dat sorgkontinuïteit vir TB-pasiënte aansienlik verbeter het nadat die intervensie geïmplementeer is. Volgens ’n prosesbeoordeling het die kenmerke van die intervensie, die eksterne konteks, die betrokke persone en die implementeringsmetodes ’n gunstige uitwerking op implementering gehad. Die interne konteks van die hospitaal was egter ongunstig vir implementering, en die hospitaal het nie met intervensieaktiwiteite volgehou nie. Daarteenoor is inligtingsteun en gemeenskapsgebaseerde nasorg en ondersteuning van TB-pasiënte wél voortgesit. Verdere wetenskaplike studies van intervensies ter verbetering van sorgkontinuïteit vir TB-pasiënte wat in soortgelyke omgewings uit die hospitaal ontslaan word, word vereis. Dít behoort aangevul te word met implementeringsnavorsing om die uitdagings van gesondheidstelsels te verstaan en die hoof te bied. Albei tipes navorsing is nodig om bewyse in die gesondheidstelsels van lae- en middelinkomstelande in praktyk om te skakel.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/107941
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