TB Guidline Observation and Adherence in Low Income Countries (TB GOAL)

描述(申请人提供)：世界卫生组织估计，如果估计的涂阳肺结核病例的70%得到确认，85%得到成功治疗，到2050年就可以实现消除结核病。1-3不幸的是，在大多数高负担国家，涂阳肺结核病例发现率远远低于70%的目标。1为了改善病例检测和管理，结核病技术援助联盟制定了名为国际结核病护理标准(ISTC)的循证指南。6对ISTC推荐的结核病嫌疑人评估做法的遵守情况在低收入国家很差。5、7改进国际结核病控制措施的实施为减轻全球结核病负担提供了巨大的机会。我们的长期目标是确定在低收入国家采取多方面干预措施以改善国际结核病控制措施的执行情况是否能降低结核病相关的发病率和死亡率。拟议的多方面干预措施涉及三类对改变行为至关重要的因素：(1)诱因因素--支持或抑制期望行为的知识或态度；(2)促成因素--促进期望行为的个人或环境的特征；(3)强化因素--遵循期望行为的预期后果。9、10因此，多方面干预措施包括(1)ISTC培训模块，以改善提供者对ISTC的知识和态度；(2)单标本显微镜(更有效的涂片显微镜策略)，以使ISTC得以遵守；以及(3)业绩反馈系统，以加强ISTC的坚持。在这项R21申请中提出的试点研究旨在评估每个干预组成部分的可行性和影响。这些数据将为未来的R01应用程序提供信息，以评估为提高ISTC遵从性而进行的多方面干预是否实际上增加了结核病病例的发现。对于试点研究，我们的假设是，每个组成部分都将提高提供者对ISTC推荐的结核病可疑评估做法的遵从性。试点研究将在乌干达传染病监测网络(UIDSN)内进行，该网络收集6个政府卫生中心的结核病护理数据(每年有10万名患者就诊)，这些中心在整个撒哈拉以南非洲都是典型的。研究对象是在6个UIDSN保健中心工作的大约50名提供者(每个保健中心3-4名临床医生、1-2名实验室技术人员和2-3名护士)。为了验证我们的假设，每个干预组件将按顺序在6个UIDSN健康中心引入。来自大约2500名结核病嫌疑人的数据将被用来客观地衡量提供商在引入每个干预组件之前和之后遵守ISTC的情况。如果成功，拟议的研究可能有助于扭转目前全球结核病发病率上升的趋势，并与NIAID预防威胁数百万人生命的传染病的使命一致。此外，这项研究将有助于更好地了解在资源有限的情况下成功实施循证指南和加强卫生系统的相关因素和干预措施类型。

DESCRIPTION (provided by applicant): The World Health Organization estimates that tuberculosis (TB) elimination can be achieved by 2050 if 70% of estimated sputum smear-positive TB cases are identified and 85% are treated successfully.1-3 Unfortunately, smear-positive TB case detection rates are far below the 70% target in most high burden countries.1 To improve case detection and management, the Tuberculosis Coalition for Technical Assistance developed evidence-based guidelines called the International Standards for TB Care (ISTC).6 Adherence to ISTC-recommended practices for TB suspect evaluation is poor in low-income countries.5,7 Thus, improving ISTC implementation offers a tremendous opportunity to reduce the global burden of TB. Our long-term objective is to determine whether a multi-faceted intervention to improve ISTC implementation reduces TB-related morbidity and mortality in low-income countries. The proposed multi-faceted intervention addresses three categories of factors that are critical for changing behavior: (1) predisposing factors - knowledge or attitudes that either support or inhibit the desired behavior; (2) enabling factors - characteristics of an individual or environment that facilitate the desired behavior; and (3) reinforcing factors -anticipated consequences of following the desired behavior.9,10 Thus, the multi-faceted intervention includes (1) ISTC training modules to improve provider knowledge and attitudes toward ISTC; (2) single-specimen microcopy (a more efficient smear microscopy strategy) to enable ISTC adherence; and (3) a performance feedback system to reinforce ISTC adherence. The pilot studies proposed in this R21 application are designed to evaluate the feasibility and impact of each of these intervention components. The data will inform a future R01 application to assess whether a multi-faceted intervention to improve ISTC adherence actually increases TB case detection. For the pilot studies, our hypothesis is that each component will improve provider adherence to ISTC-recommended TB suspect evaluation practices. The pilot studies will take place within the Uganda Infectious Disease Surveillance Network (UIDSN), which collects data on TB care at 6 government health centers (>100,000 annual patient encounters) that are typical of those seen throughout sub-Saharan Africa. The research subjects are the approximately 50 providers (3- 4 clinicians, 1-2 laboratory technicians, and 2-3 nurses per health center) working at the 6 UIDSN health centers. To test our hypothesis, each intervention component will be introduced at the 6 UIDSN health centers in a sequential fashion. Data from approximately 2500 TB suspects will be used to objectively measure provider adherence to ISTC before and after introduction of each intervention component. If successful, the proposed studies could help reverse the current trend of rising global TB incidence and are consistent with NIAID's mission to prevent infectious diseases that threaten millions of lives. In addition, this research will lead to a better understanding of the factors and types of interventions associated with successful evidence-based guideline implementation and strengthened health systems in resource-limited settings.