#1Assessment of barriers and strategies to improve tuberculosis care services in Oyo state South West Nigeria: views from patients and key stakeholders Dr O. Oladimeji, (Nigeria & South Africa) Mr E E. Udoh, (Nigeria) Prof. JM Tsoka-Gwegweni (South Africa) stop TB#2Introduction Nigeria ranks among the highest on the burden of TB worldwide. From National Survey in 2013 burden of TB was far higher than had been predicted, doubling the previous WHO estimates for TB prevalence to 323 per 100,000 population and tripling the estimates of incidence to 338 per 100,000 (NTBLCP, 2015). Effective care for tuberculosis (TB) patients and control of TB infection suffers severe impediments that are perpetually inherent in the health system, TB programming, sociocultural facets of the environment and patients attributes during ill health. Some challenges of TB management include: ➤ Misdiagnosis of cases ➤ Treatment factors such as non-adherence to treatment owing to the long duration of treatment up to 6 months on a mix of highly toxic drugs, and Unofficial treatment#3Introduction (Cont.) . • Nigeria plans universal access to high-quality, patient-centred prevention, diagnosis and treatment services for TB, TB/HIV and drug-resistant TB by 2020. To achieve these ambitious targets curbing the barriers to TB management and control is pertinent. Identifying impediments of TB care services and proffering solutions to them may assist in improvement of TB management towards reduction of TB burden.#4Objective To explore the barriers of TB care services in Nigeria and to provide strategies to improve care services.#5Methods A qualitative study conducted among the stakeholders and TB patients in Ibadan capital of Oyo State in the south western region of Nigeria. Information acquired through a focussed group discussion (FGD) and key informant interview (KII). Snowballing was done for the KII and homogeneity of participant was maintained in the selection for FGD. 7 FGDs sessions conducted among members of community service organisations (CSOs), DR-TB supporters, female TB patients, male TB patients, NGO TB group, members of TB management in the State ministry of Health and TB home care givers. 13 KII with selected health workers on TB and 6 TB patients.#6Methods ⚫ A qualitative study conducted among the . • . stakeholders and TB patients in Ibadan capital of Oyo State in the south western region of Nigeria. Ethical approval was obtained from the Oyo state Ministry of Health Ethics Committee (AD 13/ 479/1045). Additional approval was given by the University of KwaZulu-Natal, South Africa Biomedical Research Ethics Committee (BE233/16). A full consenting process was applied in respect of all participants.#7Methods (Cont.) . . . Information collected from the selected stakeholders using the voice recorder and notes taken during the interviews to contextualize the interview and focus groups findings and to confirm the validity of interpretations. Interviews were conducted in English and transcription of the audio recording was done verbatim, and using a grounded theory approach coded and analysed using Atlas.ti software. Axial coding of the content to discover major themes and subthemes and an eventual grouping into concept that reflect the existing theory influencing high burden of TB.#8Results - Barriers Program related barriers : ➤ Poor or Inadequate facilities: Inadequate facilities at the laboratories and Directly Observed Treatment Short-course (DOTS) centres. Rare application of sophisticated molecular technique for diagnosis of TB and Multidrug resistant TB (MDR-TB) using Genexpert. Neglect by responsible authorities. ➤ Shortage of TB Drugs: particularly the paediatric fixed drug combination Inadequate coverage of DOTS centres: More than half of patients interviewed noted that the distance from their homes to the DOTS centres was very far; causing financial burden and fall-out. Patients reported missing their treatment because there are no treatment centres in their own community. Health system-related barriers Lack of support and funding problems: delays in the disbursement of counterpart funds by the respective agencies meant for the running of TB programmes. Comparatively low funding for TB compared with other health interventions such as HIV/AIDS. No local funding because of lack of political will. ➤ Lack of Staff training: Some healthcare providers felt they lacked the skills and necessary knowledge to improve the TB care services. ➤ Attitude of health workers: Patients reported to suffer discrimination, maltreatment and even stigmatisation at the hands of the health workers.#9Barriers (Cont.) Patients related barriers Malnutrition and co-infection: Health workers reported that poor nutritional intake of TB patients was a major factor limiting the recovery rate of TB patients. Health providers noted that TB patients who were co-infected with HIV were more resistant to cure. ➤ Poor TB knowledge and practices: Knowledge about signs and symptoms of TB, awareness of availability of service and the proper infectious disease control practice. ➤ Non-adherence to treatment and medical advice: Deplorable health condition of the TB patients also add to hinder treatment effort and cause non-adherence. Personal Habits: Alcohol and smoking linked with recurrent tuberculosis and difficulty to cure. 'Alcohol affect effects of TB drugs.' Socio-cultural barriers ➤ Unemployment: When employees with TB are discovered they are usually dismissed immediately from their work. Stigmatisation (Health workers, family, community, work): Patients who suffer stigmatisation can be at risk of non-completion of treatment. ➤ Sociocultural Belief and patronage of traditional healers: Hinders receiving formal diagnosis and treatment for TB which can lead to complications of cases. TB as a spiritual attack that is caused by someone. In attempts to find cure for their problems through traditional and spiritual means a lot of financial losses are incurred. ➤ Overcrowding of households.#10Suggested strategies to improve TB care services • • Adopt in many other locations those effective community TB services. Ownership of TB programmes by stakeholder was suggested as imperative to sustainability of TB programmes. Capacity building of health providers to better equip health workers of the prerequisite skill and experience for management of TB cases in the community and provision of incentives and due payment to health providers. Adequate and effective counselling and treatment for TB patients. Adoption of new and advanced technologies (Xpert MTB/RIF) for diagnosis, adequate follow-up and new active case finding strategies. Provision of incentives and financial support to help ameliorate the financial burden of TB patients in seeking care. Increased awareness and education on TB through increased media awareness creation and community advocacy and sensitisation.#11• • Discussion It is noticed that some of the barriers in this study are not only peculiar to TB programmes but strongly tied to the fundamental problems of health in general in the country and in many developing nations, and of the cultural and economic conditions of the environment. Program related and health related system barriers such as inadequate drugs, inadequate funding and lack of staff training can impact on the quality of services provided, the moral of the staff, decrease adherence to treatment by patients thereby increasing rate of MDR-TB and the spread of TB. With the global gaol to eradicate TB by 2035 and Nigeria's goal to achieve a 50% reduction in TB prevalence rate and 75% reduction in TB mortality (excludes HIV-related TB) rate from the 2013 figures by 2025, a more committed action to address the barriers of TB is needed. Adhering to the suggestions from stakeholders and from patients themselves will add to ameliorate the barriers of TB care services and reduce spread of the infection.#12Recommendations . . • Decentralisation of health services closer to the patients to improve access to treatment. Full Inclusion of stakeholders in programmes for sustainability of TB of services. Increase modalities to acquire advanced technologies such as Xpert MTB/RIF for diagnosis and better-quality treatment. Motivation of TB health workers through financial benefits and staff training. Provide incentives to TB patients.#13Acknowledgment Ministry of Health, Oyo State, Nigeria College of Health Sciences, University of KwaZulu-Natal, South Africa Damien Foundation Belgium, Nigeria Project TBLBU Family, Oyo state, Nigeria Human Sciences Research Council, South Africa And all others who have contributed to successful implementation of this study..... 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