Zulu Joseph Mumba, Maritim Patricia, Halwiindi Hikabasa, Chavula Malizgani Paul, Munakampe Margarate, Matenga Tulani Francis L, Mweemba Chris, Sinyangwe Ntazana N, Habib Batuli, Musukuma Mwiche, Silumbwe Adam, Wang Bo, Kaonga Patrick, Chewe Mwimba, Fisa Ronald, Banda Jeremiah, Mubanga Angel, Phiri Henry
Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia.
Department of Health Policy and Management, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia.
Arch Public Health. 2024 Sep 14;82(1):157. doi: 10.1186/s13690-024-01384-4.
Decentralized management approaches for multi-drug-resistant tuberculosis (MDR TB) have shown improved treatment outcomes in patients. However, challenges remain in the delivery of decentralized MDR TB services. Further, implementation strategies for effectively delivering the services in community health systems (CHSs) in low-resource settings have not been fully described, as most strategies are known and effective in high-income settings. Our research aimed to delineate the specific implementation strategies employed in managing MDR TB in Zambia.
Our qualitative case study involved 112 in-depth interviews with a diverse group of participants, including healthcare workers, community health workers, patients, caregivers, and health managers in nine districts. We categorized implementation strategies using the Expert Recommendations for Implementing Change (ERIC) compilation and later grouped them into three CHS lenses: programmatic, relational, and collective action.
The programmatic lens comprised four implementation strategies: (1) changing infrastructure through refurbishing and expanding health facilities to accommodate management of MDR TB, (2) adapting and tailoring clinical and diagnostic services to the context through implementing tailored strategies, (3) training and educating health providers through ongoing training, and (4) using evaluative and iterative strategies to review program performance, which involved development and organization of quality monitoring systems, as well as audits. Relational lens strategies were (1) providing interactive assistance through offering local technical assistance in clinical expert committees and (2) providing support to clinicians through developing health worker and community health worker outreach teams. Finally, the main collective action lens strategy was engaging consumers; the discrete strategies were increasing demand using community networks and events and involving patients and family members.
This study builds on the ERIC implementation strategies by stressing the need to fully consider interrelations or embeddedness of CHS strategies during implementation processes. For example, to work effectively, the programmatic lens strategies need to be supported by strategies that promote meaningful community engagement (the relational lens) and should be attuned to strategies that promote community mobilization (collective action lens).
多药耐药结核病（MDR-TB）的分散管理方法已显示出可改善患者的治疗结果。然而，在提供分散的耐多药结核病服务方面仍存在挑战。此外，在资源匮乏地区的社区卫生系统（CHS）中有效提供这些服务的实施策略尚未得到充分描述，因为大多数策略在高收入环境中是已知且有效的。我们的研究旨在描述赞比亚在管理耐多药结核病方面采用的具体实施策略。
我们的定性案例研究包括对九个地区的医护人员、社区卫生工作者、患者、护理人员和卫生管理人员等不同群体的112人进行深入访谈。我们使用实施变革的专家建议（ERIC）汇编对实施策略进行分类，随后将其分为三个社区卫生系统视角：规划、关系和集体行动。
规划视角包括四项实施策略：（1）通过翻新和扩建卫生设施来改变基础设施，以适应耐多药结核病的管理；（2）通过实施量身定制的策略，使临床和诊断服务适应具体情况；（3）通过持续培训对卫生服务提供者进行培训和教育；（4）使用评估和迭代策略来审查项目绩效，这涉及质量监测系统的开发和组织以及审计。关系视角的策略是：（1）通过在临床专家委员会中提供本地技术援助来提供互动式援助；（2）通过组建卫生工作者和社区卫生工作者外展团队为临床医生提供支持。最后，集体行动视角的主要策略是让消费者参与；具体策略包括利用社区网络和活动增加需求以及让患者和家庭成员参与。
本研究基于ERIC实施策略，强调在实施过程中充分考虑社区卫生系统策略的相互关系或嵌入性的必要性。例如，为了有效运作，规划视角的策略需要得到促进有意义的社区参与的策略（关系视角）的支持，并且应该与促进社区动员的策略（集体行动视角）相协调。
