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70%的估计痰涂片阳性结核病病例得到识别，85%得到成功治疗，那么到2050年就可以实现结核病（TB）的消除。1 -3不幸的是，在大多数高负担国家，痰涂片阳性结核病病例的检出率远远低于70%的目标。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低收入国家对ISTC推荐的结核病可疑评估实践的遵守情况很差。5，7因此，改进ISTC的实施为减少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一个多方面的干预措施，以改善ISTC的实施，降低结核病相关的发病率和死亡率在低收入国家。建议的多方面干预针对三类对改变行为至关重要的因素：（1）诱发因素-支持或抑制预期行为的知识或态度;（2）促成因素-促进预期行为的个人或环境特征;和（3）强化因素--遵循期望行为的预期后果。9，10因此，多方面干预包括（1）ISTC培训模块，以提高提供者对ISTC的知识和态度;（2）单样本显微镜（一种更有效的涂片显微镜策略），以实现ISTC依从性;以及（3）性能反馈系统，以加强ISTC依从性。 本R21申请中提议的试点研究旨在评估每一项干预措施的可行性和影响。这些数据将为未来的R 01应用提供信息，以评估改善ISTC依从性的多方面干预是否实际上增加了结核病例的发现。 对于试点研究，我们的假设是，每个组成部分将提高供应商遵守ISTC推荐的结核病可疑评估做法。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（每年超过100，000例患者就诊）的结核病护理数据，这些数据在整个撒哈拉以南非洲地区是典型的。研究对象是在6个UIDSN卫生中心工作的大约50名提供者（每个卫生中心3- 4名临床医生，1-2名实验室技术人员和2-3名护士）。 为了检验我们的假设，每一个干预组成部分将在6个UIDSN健康中心以顺序的方式引入。来自大约2500名结核病疑似患者的数据将用于客观衡量提供者在引入每种干预成分之前和之后对ISTC的依从性。如果成功，拟议的研究将有助于扭转目前全球结核病发病率上升的趋势，并符合NIAID预防威胁数百万人生命的传染病的使命。此外，这项研究将导致更好地了解与成功实施循证指南和加强资源有限环境中的卫生系统相关的干预措施的因素和类型。 公共卫生相关性：这项R21申请的目的是改善对疑似结核病（TB）患者评估的循证指南的遵守，结核病是全球最常见的传染病之一，也是导致死亡的主要原因。在结核病最常见的资源有限的环境中，更好地执行循证指南可能是一项具有成本效益的战略，可以增加对最具传染性的结核病病例的发现和治疗，并有助于实现扭转全球结核病发病率每年增加的趋势的千年发展目标。

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. PUBLIC HEALTH RELEVANCE: The objective of this R21 application is to improve adherence to evidence-based guidelines for the evaluation of people suspected of having tuberculosis (TB), one of the most common infectious diseases and a leading cause of death worldwide. In the resource-limited settings in which TB is most common, better implementation of evidence-based guidelines could represent a cost-effective strategy to increase detection and treatment of the most infectious TB cases and help achieve the Millennium Development Goal of reversing the annual increase in global TB incidence.