Health extension workers improve tuberculosis case detection and treatment success in southern Ethiopia: a community randomized trial

Daniel G Datiko, Bernt Lindtjørn, Daniel G Datiko, Bernt Lindtjørn

Abstract

Background: One of the main strategies to control tuberculosis (TB) is to find and treat people with active disease. Unfortunately, the case detection rates remain low in many countries. Thus, we need interventions to find and treat sufficient number of patients to control TB. We investigated whether involving health extension workers (HEWs: trained community health workers) in TB control improved smear-positive case detection and treatment success rates in southern Ethiopia.

Methodology/principal finding: We carried out a community-randomized trial in southern Ethiopia from September 2006 to April 2008. Fifty-one kebeles (with a total population of 296, 811) were randomly allocated to intervention and control groups. We trained HEWs in the intervention kebeles on how to identify suspects, collect sputum, and provide directly observed treatment. The HEWs in the intervention kebeles advised people with productive cough of 2 weeks or more duration to attend the health posts. Two hundred and thirty smear-positive patients were identified from the intervention and 88 patients from the control kebeles. The mean case detection rate was higher in the intervention than in the control kebeles (122.2% vs 69.4%, p<0.001). In addition, more females patients were identified in the intervention kebeles (149.0 vs 91.6, p<0.001). The mean treatment success rate was higher in the intervention than in the control kebeles (89.3% vs 83.1%, p = 0.012) and more for females patients (89.8% vs 81.3%, p = 0.05).

Conclusions/significance: The involvement of HEWs in sputum collection and treatment improved smear-positive case detection and treatment success rate, possibly because of an improved service access. This could be applied in settings with low health service coverage and a shortage of health workers.

Trial registration: ClinicalTrials.gov NCT00803322.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Map of the study area…
Figure 1. Map of the study area in Sidama zone in south Ethiopia.
Shaded area - Intervention kebeles. White area with black box - Control kebeles. Red box - Health centers and health stations.
Figure 2. Trial profile for smear-positive TB…
Figure 2. Trial profile for smear-positive TB case finding and treatment outcome.

References

    1. Harries A, Maher Dermot, Graham Stephan. TB/HIV: A Clinical Manual. Geneva, Switzerland: WHO; 2004. p. 210.
    1. Subramani R, Radhakrishna S, Frieden TR, Kolappan C, Gopi PG, et al. Rapid decline in prevalence of pulmonary tuberculosis after DOTS implementation in a rural area of South. India Int J Tuberc Lung Dis. 2008;12:916–920(915).
    1. Dye C, Watt CJ, Bleed DM, Williams BG. What is the limit to case detection under the DOTS strategy for tuberculosis control? Tuberculosis. 2003;83:35–43.
    1. Murray CJ, Salomon JA. Expanding the WHO tuberculosis control strategy: rethinking the role of active case finding. Int J Tuberc Lung Dis. 1998;2:S9–S15.
    1. Golub JE, Mohan CI, Comstock GW, Chaisson RE. Active case finding of tuberculosis: historical perspective and future prospects. Int J Tuberc Lung Dis. 2005;9:1183–1203.
    1. Federal Ministry of Health of Ethiopia. Tuberculosis, Leprosy and TB/HIV Prevention and Control Manual. Addis Ababa, Ethiopia: Ministry of Health; 2008.
    1. Federal Ministry of Health of Ethiopia. Essential health Service Package for Ethiopia. Addis Ababa: Artistic printing Enterprise; 2005. Health FMo, editor.
    1. World Health Organization. Global Tuberculosis Control, surveillance, planning and financing. Geneva, Switzerland: World Health Organization; 2008. pp. 1–304.
    1. Donner A, Klar N. Design and analysis of cluster randomization trials in health research. London: Arnold; 2000.
    1. Donner A, N. K. Methods for comparing event rates in intervention studies when the unit of allocation is a cluster. Am J Epidemiology. 1994;140:279–289.
    1. Ukoumunne OC, Gulliford MC, Chinn S, Sterne JA, Burney PG. Methods for evaluating area-wide and organization-based interventions in health and health care: a systematic review. Health Technol Assess. 1999;3:92.
    1. Kivihya-Ndugga LE, van Cleeff MR, Ng'ang'a LW, Meme H, Odhiambo JA, et al. Sex-specific performance of routine TB diagnostic tests. Int J Tuberc Lung Dis. 2005;9:294–300.
    1. Agboatwalla M, Kazi GN, Shah SK, Tariq M. Gender perspectives on knowledge and practices regarding tuberculosis in urban and rural areas in Pakistan. East Mediterr Health J. 2003;9:732–740.
    1. Ahsan G, Ahmed J, Singhasivanon P, Kaewkungwal J, Okanurak K, et al. Gender difference in treatment seeking behaviors of tuberculosis cases in rural communities of Bangladesh. Southeast Asian J Trop Med Public Health. 2004;35:126–135.
    1. Hamid Salim MA, Declercq E, Van Deun A, Saki KA. Gender differences in tuberculosis: a prevalence survey done in Bangladesh. Int J Tuberc Lung Dis. 2004;8:952–957.
    1. Dye C, Hosseini Mehran, Watt Catherine. Did we reach the 2005 targets for tuberculosis control? Bulletin of the World Health Organization. 2007;85:364–369.
    1. Wahyuni C, Budiono X, Rahariyani LD, Sulistyowati M, Rachmawati T, et al. Obstacles for optimal tuberculosis case detection in primary health centers (PHC) in Sidoarjo district, East Java, Indonesia. BMC Health Serv Res. 2007;7:135.
    1. Enarson DA. World tuberculosis control: how far have we to go? Int J Tuberc Lung Dis. 2000;4:219–223.
    1. Shargie EB, Morkve O, Lindtjorn B. Tuberculosis case-finding through a village outreach programme in a rural setting in southern Ethiopia: community randomized trial. Bull World Health Organ. 2006;84:112–119.
    1. Santha T, Renu G, Frieden TR, Subramani R, Gopi PG, et al. Are community surveys to detect tuberculosis in high prevalence areas useful? Results of a comparative study from Tiruvallur District, South India. Int J Tuberc Lung Dis. 2003;7:258–265.
    1. Omaswa F. The Community TB Care in Africa. Int J Tuberc Lung Dis. 2003;7:S1–S102.
    1. World Health Organization. Community TB care: Practice and Policy. 2003.
    1. Shargie EB, Yassin MA, Lindtjorn B. Prevalence of smear-positive pulmonary tuberculosis in a rural district of Ethiopia. Int J Tuberc Lung Dis. 2006;10:87–92.
    1. World Health Organization. Global Tuberculosis Control, surveillance, planning and financing. Geneva, Switzerland: 2007. pp. 1–270.
    1. Wandwalo E, Kapalata N, Egwaga S, Morkve O. Effectiveness of community-based directly observed treatment for tuberculosis in an urban setting in Tanzania: a randomised controlled trial. Int J Tuberc Lung Dis. 2004;8:1248–1254.
    1. Singh AA, Parasher D, Shekhavat GS, Sahu S, Wares DF, et al. Effectiveness of urban community volunteers in directly observed treatment of tuberculosis patients: a field report from Haryana, North India. Int J Tuberc Lung Dis. 2004;8:800–802.
    1. Kangangi JK, Kibuga D, Muli J, Maher D, Billo N, et al. Decentralisation of tuberculosis treatment from the main hospitals to the peripheral health units and in the community within Machakos district, Kenya. Int J Tuberc Lung Dis. 2003;7:S5–13.
    1. Golub JE, Mohan CI, Comstock GW, Chaisson RE. Active case finding of tuberculosis: historical perspective and future prospects. Int J Tuberc Lung Dis. 2005;9:1183–1203.
    1. Leung CC, Yew WW, Chan TY, Tam CM, Chan CY, et al. Seasonal pattern of tuberculosis in Hong Kong. Int J Epidemiol. 2005;34:924–930.
    1. Thorpe LE, Frieden TR, Laserson KF, Wells C, Khatri GR. Seasonality of tuberculosis in India: is it real and what does it tell us? Lancet. 2004;364:1613–1614.
    1. Luquero FJ, Sanchez-Padilla E, Simon-Soria F, Eiros JM, Golub JE. Trend and seasonality of tuberculosis in Spain, 1996–2004. Int J Tuberc Lung Dis. 2008;12:221–224.

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